Floormat physiological sensor

ABSTRACT

A stand-on physiological sensor (e.g. floormat) measures vital signs and various hemodynamic parameters, including blood pressure and ECG waveforms. The sensor is similar in configuration to a common bathroom scale and includes electrodes that take electrical measurements from a patient&#39;s feet to generate bioimpedance waveforms, which are analyzed digitally to extract various other parameters, as well as a cuff-type blood pressure system that takes physical blood pressure measurements at one of the patient&#39;s feet. Blood pressure can also be calculated/derived from the bioimpedance waveforms. Measured parameters are transmitted wirelessly to facilitate remote monitoring of the patient for heart failure, chronic heart failure, end-stage renal disease, cardiac arrhythmias, and other degenerative diseases.

BACKGROUND AND FIELD OF THE INVENTION

1. Field of the Invention

The invention relates to sensors that measure physiological signals frompatients, and the use of such sensors.

2. General Background

Known electrical or digital weight scales typically use a load cell,integrated into a Wheatstone Bridge circuit, to measure a patient'sweight. In such devices, the load cell exhibits a small, force-dependentresistance changes when the patient steps on the scale. The WheatstoneBridge features four resistors, at least one of which is part of theload cell, and a measurable/ascertainable voltage change across Bridgevaries with the force applied to the load cell. The voltage change thuscorrelates to the patient's weight. Once the scale is calibrated, thevoltage is digitized and processed and ultimately converted into aweight, which is then displayed to the patient.

More advanced electrical or digital weight scales include stainlesssteel electrodes and associated circuitry to measure the patient'sbioimpedance and/or bioreactance signals. Algorithms process parametersextracted from these signals to estimate parameters such as percent bodyfat and muscle mass.

Other known sensors measure physiological signals from a patient todetermine time-varying waveforms, e.g. thoracic bioimpedance (TBI) andelectrocardiogram (ECG) waveforms, with electrodes that attach to thepatient's skin. These waveforms can be processed/analyzed to extractother medically relevant parameters such as heart rate (HR), respirationrate (RR), heart rate variability (HRV), stroke volume (SV), cardiacoutput (CO), and information relating to thoracic fluids, e.g. thoracicfluid index (TFC). Certain physiological conditions can be identifiedfrom these parameters using one-time measurements; other conditionsrequire observation of time-dependent trends in the parameters in orderto identify the underlying condition. In all cases, it is important tomeasure the parameters with high repeatability and accuracy.

Some conditions require various physiological parameters to be measuredover a relatively short period of time in order to identify thecondition. For example, Holter monitors can characterize various typesof cardiac arrhythmias by measuring HR, HRV, and ECG waveforms overperiods ranging from a day to a few weeks. On the other hand, chronicdiseases such as congestive heart failure (CHF) and end-stage renaldisease (ESRD) typically require periodic measurements of fluids andweight throughout the patient's life in order to identify the condition.Not surprisingly, patient compliance with measurement routines typicallydecreases as the measurement period increases. This is particularly truewhen measurements are made outside of a conventional medical facility,e.g., at the patient's home or in a residential facility such as anursing home.

Furthermore, the measured values of some physiological parameters willvary with the location at which the parameters are measured, while thoseassociated with other physiological parameters are relativelyindependent of the location at which the parameters are measured. Forexample, parameters such as HR, which depends on the time-dependentvariation of R-R intervals in ECG waveforms, are relatively insensitiveto sensor positioning. Likewise, pulse oximetry (SpO2) and pulse rate(PR), as measured with a pulse oximeter, show little variance withmeasurement location.

On the other hand, measurements that depend on amplitude-dependentfeatures in waveforms, such as TFC, will be strongly dependent on themeasurement location, e.g. the positioning of electrodes. In the case ofTFC, for example, the measured value depends strongly on the sensedimpedance between a set of electrodes. And this, in turn, will vary withthe electrodes' placement. For TFC deviation in the day-to-day placementof the electrodes can result in measurement errors. This, in turn, canlead to misinformation (particularly when trends of the measuredparameters are to be extracted), thereby nullifying the value of suchmeasurements and thus negatively impacting treatment.

Like TFC, measured values of blood pressure (e.g. systolic (SYS) anddiastolic (DIA) pressure), are typically sensitive to the location atwhich the parameter is measured. For example, blood pressure measured atthe brachial artery with a sphygmomanometer (i.e. a manual bloodpressure cuff) or with an oscillometric device (i.e. an automated bloodpressure cuff) will typically be different from that measured at otherlocations on the body, such as the wrist, thigh, finger, or even theopposite arm. Body temperature (TEMP) is similarly dependent on thelocation at which it is measured.

Sensors, Devices, and Relevant Physiology

Disposable electrodes that measure ECG and TBI waveforms are typicallyworn on the patient's chest or legs and include: i) a conductivehydrogel that contacts the patient's skin; ii) a Ag/AgCl-coated eyeletthat contacts the hydrogel; iii) a conductive metal post that connectsto a lead wire or cable extending from the sensing device; and iv) anadhesive backing that adheres the electrode to the patient.Unfortunately, during a measurement, the lead wires can pull on theelectrodes if the device is moved relative to the patient's body, or ifthe patient ambulates and snags the lead wires on surrounding objects.Such pulling can be uncomfortable or even painful, particularly wherethe electrodes are attached to hirsute parts of the body, and this caninhibit patient compliance with long-term monitoring. Moreover, theseactions can degrade or even completely eliminate adhesion of theelectrodes to the patient's skin, and in some cases completelydestroying the electrodes' ability to sense the physiological signals atvarious electrode locations.

Some devices that measure ECG and TBI waveforms are worn entirely on thepatient's body. These devices have been developed to feature simple,patch-type systems that include both analog and digital electronicsconnected directly to underlying electrodes. Such devices, like theHolter monitors described above, are typically prescribed for relativelyshort periods of time, e.g. for a period of time ranging from a day toseveral weeks. They are typically wireless and include features such asBluetooth® transceivers to transmit information over a short distance toa second device, which then transmits the information via a cellularradio to a web-based system.

SpO2 values are almost always measured at the patient's fingers,earlobes, or, in some cases, toes. In these cases, patients wear anoptical sensor to measure photoplethysmogram (PPG) waveforms, which arethen processed to yield SpO2 and PR values. TEMP is typically measuredwith a thermometer inserted into the patient's mouth.

Assessing TFC, weight, and hydration status is important in thediagnosis and management of many diseases. For example, ESRD occurs whena patient's kidneys are no longer able to work at a level needed forday-to-day life. The disease is most commonly caused by diabetes andhigh blood pressure, and is characterized by swings in SYS and DIA alongwith a gradual increase in fluids throughout the body. Patientssuffering from ESRD typically require hemodialysis or ultrafiltration toremove excess fluids. Thus, accurate measurement of TFC to identify ESRDcan eliminate the need for empirical clinical estimations that oftenlead to over-removal or under-removal of fluid during dialysis, therebypreventing hemodynamic instability and hypotensive episodes (Anand etal., “Monitoring Changes in Fluid Status With a Wireless MultisensorMonitor: Results From the Fluid Removal During Adherent Renal Monitoring(FARM) Study,” Congest Heart Fail. 2012; 18:32-36). A similar situationexists with respect to CHF, which is a complicated disease typicallymonitored using a “constellation” of physiological factors, e.g., fluidstatus (e.g. TFC), vital signs (i.e., HR, RR, TEMP, SYS, DIA, and SpO2),and hemodynamic parameters (e.g. CO, SV). Accurate measurement of theseparameters can aid in managing patients, particularly in connection withdispensing diuretic medications, and thus reduce expensive hospitalreadmissions (Packer et al., “Utility of Impedance Cardiography for theIdentification of Short-Term Risk of Clinical Decompensation in StablePatients With Chronic Heart Failure,” J Am Coll Cardiol 2006;47:2245-52).

CHF is a particular type of heart failure (HF), which is a chronicdisease driven by complex pathophysiology. In general terms, HF occurswhen SV and CO are insufficient to adequately perfuse the kidneys andlungs. Causes of this disease are well known and typically includecoronary heart disease, diabetes, hypertension, obesity, smoking, andvalvular heart disease. In systolic HF, ejection fraction (EF) can bediminished (<50%), whereas in diastolic HF this parameter is typicallynormal (>65%). The common signifying characteristic of both forms ofheart failure is time-dependent elevation of the pressure within theleft atrium at the end of its contraction cycle, or left ventricularend-diastolic pressure (LVEDP). Chronic elevation of LVEDP causestransudation of fluid from the pulmonary veins into the lungs, resultingin shortness of breath (dyspnea), rapid breathing (tachypnea), andfatigue with exertion due to the mismatch of oxygen delivery and oxygendemand throughout the body. Thus, early compensatory mechanisms for HFthat can be detected fairly easily include increased RR and HR.

As CO is compromised, the kidneys respond with decreased filtrationcapability, thus driving retention of sodium and water and leading to anincrease in intravascular volume. As the LVEDP rises, pulmonary venouscongestion worsens. Body weight increases incrementally, and fluids mayshift into the lower extremities. Medications for HF are designed tointerrupt the kidneys' hormonal responses to diminished perfusion, andthey also work to help excrete excess sodium and water from the body.However, an extremely delicate balance between these two biologicaltreatment modalities needs to be maintained, since an increase in bloodpressure (which relates to afterload) or fluid retention (which relatesto preload), or a significant change in heart rate due to atachyarrhythmia, can lead to decompensated HF. Unfortunately, thiscondition is often unresponsive to oral medications. In that situation,admission to a hospital is often necessary for intravenous diuretictherapy.

In medical centers, HF is typically detected using Doppler/ultrasound,which measures parameters such as SV, CO, and EF. In the homeenvironment, on the other hand, gradual weight gain measured with asimple weight scale is likely the most common method used to identifyCHF. However, by itself, this parameter is typically not sensitiveenough to detect the early onset of CHF—a particularly important stagein the condition when the condition may be ameliorated simply andeffectively by a simple change in medication or diet.

SV is the mathematical difference between left ventricular end-diastolicvolume (EDV) and end-systolic volume (ESV), and represents the volume ofblood ejected by the left ventricle with each heartbeat; a typical valueis about 70-100 mL. EF relates to EDV and ESV as described below inEquation 1:

$\begin{matrix}{{EF} = {\frac{SV}{EDV} = \frac{{EDV} - {ESV}}{EDV}}} & (1)\end{matrix}$

CO is the average, time-dependent volume of blood ejected from the leftventricle into the aorta and, informally, indicates how efficiently apatient's heart pumps blood through their arterial tree; a typical valueis about 5-7 L/min. CO is the product of HR and SV, i.e.,

CO=SV×HR  (2)

CHF patients—particular those suffering from systolic HF—may receiveimplanted devices such as pacemakers and/or cardioverter-defibrillatorsto increase EF and subsequent blood flow throughout the body. Thesedevices may include circuitry and algorithms to measure the electricalimpedance between different leads of the device. Some implanted devicesprocess this impedance to calculate a “fluid index”. As thoracic fluidincreases in the CHF patient, the impedance typically is reduced, andthe fluid index increases. Thus, the fluid index, when read by aninterrogating device placed outside the patient's body, can indicate theonset of heart failure.

Clinical Solutions

Many of the above-mentioned parameters can be used as early markers orindicators that signal the onset of CHF. EF is typically low in patientssuffering from this chronic disease, and it can be further diminished byfactors such as a change in physiology, an increase in sodium in thepatient's diet, or non-compliance with medications. This is manifestedby a gradual decrease in SV, CO, and SYS that typically occurs betweentwo and three weeks before hospitalization becomes necessary to treatthe condition. The reduction in SV and CO diminishes perfusion to thekidneys. As noted above, these organs then respond with a reduction intheir filtering capacity, thus causing the patient to retain sodium andwater and leading to an increase in intravascular volume. This, in turn,leads to congestion, which is manifested to some extent by a build-up offluids in the patient's thoracic cavity (e.g. TFC). Typically, adetectable increase in TFC occurs about 1-2 weeks before hospitalizationbecomes necessary. Body weight increases after this event (typically bybetween three and five pounds), thus causing fluids to shift into thelower extremities. At this point, the patient may experience an increasein both HR and RR to increase perfusion. Nausea, dyspnea, and weightgain typically grow more pronounced a few days before hospitalizationbecomes necessary. As noted above, a characteristic of decompensated HFis that it is often unresponsive to oral medications; thus, at thispoint, intravenous diuretic therapy in a hospital setting often becomesmandatory. A hospital stay for intravenous diuretic therapy typicallylasts about 4 days, after which the patient is discharged and theabove-described cycle may start over once again.

Such cyclical pathology and treatment is physically taxing on thepatient, and economically taxing on society. In this regard, CHF andESRD affect, respectively, about 5.3 million and 3 million Americans,resulting in annual healthcare costs estimated at $45 billion for CHFand $35 billion for ESRD. CHF patients account for approximately 43% ofannual Medicare expenditures, which is more than the combinedexpenditures for all types of cancer. Somewhat disconcertingly, roughly$17 billion of this is attributed to hospital readmissions. CHF is alsothe leading cause of mortality for patients with ESRD, and thisdemographic costs Medicare nearly $90,000/patient annually. Thus, thereunderstandably exists a profound financial incentive to keep patientssuffering from these diseases out of the hospital. Starting in 2012,U.S. hospitals have been penalized for above-normal readmission rates.Currently, the penalty has a cap of 1% of payments, growing to over 3%in the next three years.

Of some promise, however, is the fact that CHF-related hospitalreadmissions can be reduced when clinicians have access to detailedinformation that allows them to remotely titrate medications, monitordiet, and promote exercise. In fact, Medicare has estimated that 75% ofall patients with ESRD and/or CHF could potentially avoid hospitalreadmissions if treated by simple, effective programs.

Thus, in order to identify precursors to conditions such as CHF andESRD, physicians can prescribe physiological monitoring regimens topatients living at home. Typically, such regimens require the use ofmultiple standard medical devices, e.g. blood pressure cuffs, weightscales, and pulse oximeters. In certain cases, patients use thesedevices daily and in a sequential manner, i.e., one device at a time.The patient then calls a central call center to relay their measuredparameters to the call center. In more advanced systems, the devices arestill used in a sequential manner, but they automatically connectthrough a short-range wireless link (e.g. a Bluetooth® system) to a“hub,” which then forwards the information to a call center. Often, thehub features a simple user interface that presents basic questions tothe patient, e.g. questions concerning their diet, how they are feeling,and whether or not medications were taken.

Ultimately, however, and regardless of how sophisticated suchinstrumentation may be, in order for such monitoring to betherapeutically effective, it is important for the patient to use theirequipment consistently, both in terms of the duration and manner inwhich it is used. Less-than-satisfactory consistency with the use of anymedical device (in terms of duration and/or methodology) may beparticularly likely in an environment such as the patient's home or anursing home, where direct supervision may be less than optimal.

SUMMARY OF THE INVENTION

In view of the foregoing, it would be beneficial to provide aphysiological sensor or monitoring device that is suitable for home use.Particularly valuable would be a monitoring device that convenientlymeasures a collection of vital signs and hemodynamic parameters, andwhich fosters patient compliance and regular use. Ideally, themonitoring device is easy to use and features a simple form factor thatintegrates into the patient's day-to-day activities. A sensor accordingto the invention, which facilitates monitoring a patient for HF, CHF,ESRD, cardiac arrhythmias, and other diseases, is designed to achievethis goal.

More specifically, the sensor according to this invention is configuredgenerally like a floormat or conventional weight-measuring scale, andtherefore is referred to colloquially herein as “the floormat.” Using aplurality of sensors, the floormat measures and/or calculates all vitalsigns along with the sophisticated hemodynamic parameters discussedabove in just a few moments (i.e., on the order of two or threeminutes).

Preferably the floormat is used daily, and collects information that canbe analyzed to determine time-dependent trends. It sends informationthrough a wireless interface, which typically includes the patient'smobile device (e.g. a tablet or smartphone), to a web-based system. Theinformation it collects may be analyzed to detect the early onset ofmany diseases, e.g. CHF. Ultimately, the floormat can provide clinicianswith information that, when acted on, may prevent hospitalization.

More particularly, the floormat measures the following parameters from apatient: HR, PR, SpO2, RR, SYS, DIA, TEMP, a thoracic fluid index (TFI),SV, CO, weight, percent body fat, muscle mass, and parameters sensitiveto blood pressure called pulse arrival time (PAT) and vascular transittime (VTT). Collectively, as used herein, PAT and VTT are referred to aspulse transit times (PTTs).

The floormat measures SYS and DIA using a pressure-delivery system thatfeatures a bladder similar to a blood pressure cuff. Additionally, usingSV, a first algorithm employing a linear model can estimate thepatient's pulse pressure (PP). And following this pressure-applyingmeasurement, a second algorithm can process PP, PAT and/or VTT, and acalibration from the pressure-applying measurement to estimate SYS andDIA in a cuffless fashion. Thus the floormat can measure blood pressureusing both cuff-based and cuffless techniques. Advantageously, with thisconfiguration, blood pressure values obtained using the direct,pressure-applying mechanism can be used to calibrate the cuffless bloodpressure components (hardware and/or software), e.g., every two weeks orso, to keep the accuracy of the floormat optimal. (In other words, thefloormat—as an overall, integrated device—is self-calibrating.) In thismanner, patients who are averse to having their blood pressure takenusing a cuff can minimize their use of the pressure-applyingmeasurement, relying on it occasionally for such calibration purposeswhile maintaining the floormat's ability to provide accurate,therapeutically meaningful information.

More particularly, as described in greater detail below, the floormatmeasures the above-described parameters when a patient stands on it forabout 2 minutes. To accomplish this, the floormat includes the followingsensor subsystems: 1) an ECG system, with two permanent, integrated ECGelectrodes that are used to generate an ECG waveform from which HR andHRV are determined; 2) an impedance system, with four permanent,integrated impedance electrodes that are used to generate a bioimpedance(BI) waveform from which TFI, SV, CO, body fat, and muscle mass valuesare determined; 3) an optical system that generates a collection of PPGwaveforms from which SpO2 is determined; 4) a direct orpressure-applying blood pressure system, including an inflatable bladderhousing the optical system, that applies a light pressure to thepatient's foot and generates a pressure waveform for determining bloodpressure; and 5) a scale system that measures the patient's weight alongwith percent body fat and muscle mass. The ECG and impedance electrodes,which suitably are made from stainless steel or other conductivematerial, are generally located on the floormat's top surface so as tomake contact with the soles of the patient's feet when the patient stepsonto the floormat. The system may also have an additional electrode thatthe patient holds during a measurement, which provides for alternateelectrical pathways through the body that can be used to cross-checkagainst the physiological parameter values obtained via foot-to-footelectrical pathways.

A digital processing system featuring a microprocessor, a wirelesstransmitter, and an analog-to-digital converter processes waveformsmeasured/generated by the corresponding sensor of each of the varioussubsystems to determine the associated physiological informationdescribed above. A rechargeable battery powers the floormat.

The floormat transmits information to a mobile device, e.g. a cell phoneor tablet computer, which can display numerical values, waveforms,graphs, etc. The mobile device, in turn, transmits information to aweb-based system, where it can be viewed, e.g., by patients, clinicians,and family members.

More specifically, in one aspect, the invention features a system formeasuring a blood pressure value from a patient. The system includes: 1)a base featuring a bottom surface configured to rest on or near asubstantially horizontal surface, and a top surface configured toreceive at least one of the patient's feet; 2) a pressure-deliverysystem connected to the top surface and including an opening whichcovers a portion of at least one of the patient's feet when it is incontact with the top surface, an featuring a flexible member configuredto apply pressure to a portion of at least one of the patient's feet anda pressure sensor configured to measure the applied pressure; and 3) aprocessing system in electrical contact with the pressure sensor, andconfigured to receive signals from it and convert them into a set ofpressure values, and then analyze the set of pressure values todetermine the blood pressure value.

The structure, as used herein, is an embodiment of the floormat.

In another aspect, the system also includes a weight-measuring systemconnected to the structure's top surface and featuring an electricalsystem that measures a set of voltages that correlates with a forceapplied to the top surface.

In embodiments, the flexible member is a bladder (that can be filled,e.g., with a fluid such as air), and the pressure-delivery systemincludes a pump. The pump connects to the bladder and, in embodiments, avalve, and is configured to pump air into the bladder when the pump ispowered on. The pressure sensor connects to the bladder and isconfigured to measure a pressure within the bladder. In embodiments, thebladder is formed as a strap that receives air from the pump, with afirst distal end of the strap connected to the top surface, and a seconddistal end of the strap connected to the top surface.

Typically the processing system features computer code that analyzes theset of pressure values to determine the blood pressure value. Thecomputer code can run on, e.g., a microcontroller or microprocessor. Forexample, the pressure values can be a set of pressure-dependentoscillations that depend on the patient's blood pressure, and thecomputer code can analyze these to determine a blood pressure value.Typically, each pressure-dependent oscillation in the set ofpressure-dependent oscillations is characterized by a pressure andamplitude value, and the computer code is further configured todetermine the pressure-dependent oscillation having a maximum amplitudevalue. From this the system calculates the MAP. In related embodiments,the computer code is further configured to determine SYS from a firstpressure-dependent oscillation characterized by an amplitude that, whendivided by the maximum amplitude of the pressure-dependent oscillations,is substantially equivalent to a first pre-determined ratio (typicallybetween 0.4-0.8, and most preferably about 0.6). In yet another relatedembodiment, the computer code is further configured to determine DIAfrom a second pressure-dependent oscillation characterized by anamplitude that, when divided by the maximum amplitude of thepressure-dependent oscillations, is substantially equivalent to a secondpre-determined ratio (typically between 0.4-0.8, and most preferablyabout 0.7).

In embodiments, the set of pressure-dependent oscillations are measuredwhile the pressure-delivery system inflates or deflates the flexiblemember.

In other embodiments, the electrical system within the weight-measuringsystem features a Wheatstone Bridge that connects electrically with anamplifier system. Here, the system's processing system is furtherconfigured to receive the set of voltages, and analyze them to determinea value of weight corresponding to the force applied on the top surface.

In another aspect, the invention features a system for measuring astroke volume value from a patient. The system features: 1) a mechanicalstructure similar to that described above; 2) an electrical impedancesystem connected to the structure's top surface and including at leastfour electrodes, at least one of which is configured to inject anelectrical current into the patient's feet, and at least one of which isconfigured to measure a signal induced by the electrical current andrepresentative of an impedance plethysmogram; and 3) a processing systemin electrical contact with the electrical impedance system, andconfigured to receive signals from it and convert them into a set ofimpedance values which it then analyzes to determine the stroke volumevalue.

In embodiments, the system for measuring a stroke volume value featuresa weight-measuring system similar to that described above.

In other embodiment, the electrical impedance system features anelectrical system that injects a current modulated at a frequencybetween 25-125 kHz (and preferably about 100 kHz). Typically theelectrical impedance system features two electrodes that inject theelectrical current that are disposed on the structure's top surface,with one electrode located substantially on the left-hand side of thetop surface and configured to inject electrical current into thepatient's left foot, and one electrode located substantially on theright-hand side of the top surface and configured to inject electricalcurrent into the patient's right foot. It also typically includes twoadditional electrodes, each configured to measure a signal induced bythe electrical current, wherein both electrodes are connected to the topsurface, and one electrode is located substantially on the left-handside of the top surface and configured to measure a signal from thepatient's left foot, and one electrode is located substantially on theright-hand side of the top surface and configured to measure a signalfrom the patient's right foot. In other embodiments, the system alsoincludes a hand-held component with at least two electrodes similar tothose described above.

In embodiments, the processing system features computer code configuredto analyze the set of impedance values to determine the stroke volumevalue. For example, the computer code can calculate a derivative of theset of impedance values to determine a dΔZ(t)/dt waveform, from which itcalculates a maximum value or an area of a pulse therein. The computercode can also analyze the dΔZ(t)/dt waveform to determine an ejectiontime or a baseline impedance (Z₀) value. The computer code can thenprocess these values to determine SV using the equation:

$\begin{matrix}{{SV} \sim {\frac{( {d\; \Delta \; {Z(t)}\text{/}{dt}} )_{\max}}{Z_{o}} \times {LVET}}} & (3)\end{matrix}$

or, alternatively, the equation:

$\begin{matrix}{S\; V\text{∼}\sqrt{\frac{( {d\; \Delta \; {{Z(t)}/{dt}}} )_{\max}}{Z_{o}}} \times L\; V\; E\; T} & (4)\end{matrix}$

In embodiments, the system's weight-measuring system measures a set ofvoltages that correlates with a force applied to the top surface, andfrom these calculate the user's weight. The processing system can thenuse the weight to determine SV from the equation:

$\begin{matrix}{{S\; V} = {V_{c} \times \frac{( {d\; \Delta \; {{Z(t)}/{dt}}} )_{\max}}{Z_{o}} \times L\; V\; E\; T}} & (5)\end{matrix}$

or, alternatively, the equation:

$\begin{matrix}{{S\; V} = {V_{c} \times \sqrt{\frac{( {d\; \Delta \; {{Z(t)}/{dt}}} )_{\max}}{Z_{o}}} \times L\; V\; E\; T}} & (6)\end{matrix}$

where V_(c) is a volume conductor calculated from the value of weight.

In still other aspects, the system calculates CO by also measuring HR asdescribed below (e.g. using an ECG waveform), and then collectivelyprocessing SV and HR (e.g., by taking the product) to determine CO.

In another aspect, the invention provides a system for measuring an SpO2value from a patient. The system features: 1) a mechanical structuresimilar to that described above; 2) an optical system connected to thestructure's top surface and featuring a first light source that emitsinfrared radiation, a second light source that emits red radiation, anda photodetector configured to receive infrared and red radiation afterit irradiates at least one of the patient's feet to generate,respectively, a first and second set of signals; and 3) a processingsystem in electrical contact with the optical system, and configured toreceive the first and second set of signals from the optical system andconvert them into, respectively, a first and second set of values thatit then analyzes to determine the SpO2.

In embodiments, the system for measuring an SpO2 value features aweight-measuring system similar to that described above.

In embodiments, the first light source is configured to emit opticalradiation between 880 and 920 nm (preferably about 905 nm) and thesecond light source is configured to emit optical radiation between 640and 680 nm (preferably about 660 nm). Typically the first and secondlight sources and the photodetector are connected directly to thestructure's top surface, and the photodetector is configured to receiveinfrared and red radiation after it reflects off one of the patient'sfeet. Alternatively, the first and second light sources are connected toa member that, in turn, connects directly to the structure's topsurface, and the member is configured to cover at least a portion of oneof the patient's feet. For example, the member can be a flexible strapconnected at its distal ends to the top surface. In this case, thephotodetector is connected directly to the structure's top surface, andis configured to receive infrared and red radiation after it transmitsthrough the patient's feet.

In embodiments, the processing system features computer code configuredto analyze the first set of values to determine an AC component(infrared(AC)) and a DC component (infrared(DC)), and the second set ofvalues to determine an AC component (red(AC)) and a DC component(red(DC)). It then processes these components to determine the SpO2value. Processing, for example, may use the following equation todetermine a ratio of ratios (RoR):

$\begin{matrix}{{R\; o\; R} = \frac{{red}\mspace{14mu} {({AC})/{red}}\mspace{14mu} ({DC})}{{infrared}\mspace{14mu} {({AC})/{infrared}}\mspace{14mu} ({DC})}} & (7)\end{matrix}$

and then determine the RoR according to the following equation todetermine the SpO2 value:

SpO2value=(a+b×RoR+c×RoR)×100  (8)

wherein a, b, and c are pre-determined constants.

In another aspect, the invention provides a system for measuring an RRvalue from a patient. The system features: 1) a mechanical structuresimilar to that described above; 2) an electrical impedance systemsimilar to that described above and connected to the structure's topsurface and configured to measure an impedance plethysmogram; and 3) aprocessing system in electrical contact with the electrical impedancesystem, and configured to receive signals from it and convert them intoa set of impedance values that it then analyzes to determine the RRvalue.

In embodiments, the system for measuring an RR value features aweight-measuring system similar to that described above.

In embodiments, the electrical impedance system is similar to thefour-electrode system described above, and may include the hand-heldcomponent. Here, the processing system includes computer code configuredto analyze the set of impedance values to determine the RR value. Duringuse, for example, the electrical system generates impedance values thatinclude oscillations, and the processing system's computer code analyzesoscillations to determine the RR value. Alternatively, the set ofimpedance values feature time-dependent pulsations, and the processingsystem's computer code analyzes a separation in neighboring pulsationsto determine the RR value. Or the computer code can determine amathematical derivative of the set of impedance values, and then processthis to determine the RR value.

In another aspect, the invention provides a system for measuring a PTTvalue from a patient. The system features: 1) a mechanical structuresimilar to that described above; 2) an electrical impedance systemsimilar to that described above that generates a first set of signalsrepresentative of an impedance plethysmogram; 3) a heart rate monitoringsystem connected to the mechanical structure and featuring adifferential amplifier configured to measure a second set of signalsrepresentative of a cardiac rhythm from the patient; and 4) a processingsystem in electrical contact with the electrical impedance system andthe heart rate monitoring system, and configured to: i) receive thefirst signals from the electrical impedance system and convert them intoa set of impedance values; ii) analyze the set of impedance values todetermine a first time value indicating a first pulsatile component;iii) receive the second set of signals from the heart rate monitoringsystem and convert them into a set of cardiac rhythm values; iv) analyzethe set of cardiac rhythm values to determine a second pulsatilecomponent; and v) collectively process the first and second pulsatilecomponents to determine the PTT value.

In embodiments, the system for measuring a PTT value features aweight-measuring system similar to that described above.

In embodiments, the processing system features computer code configuredto: i) calculate a mathematical derivative of the impedance values todetermine a set of derivative values; and ii) determine a local maximumof the set of derivative values to determine the first pulsatilecomponent; and/or iii) determine a zero-point crossing of the set ofderivative values to determine the first pulsatile component. Thecomputer code may also be configured to: i) estimate the set ofderivative values with a mathematical function; and ii) analyze themathematical function to determine the first pulsatile component.

In embodiments, the computer code is configured to determine a localmaximum of the cardiac rhythm values to determine the second pulsatilecomponent, and the cardiac rhythm values are representative of an ECGwaveform. For example, the computer code can be configured to determinea QRS complex (e.g. calculate the Q or R point) in the ECG waveform todetermine the second pulsatile component. It can also further processthe cardiac rhythm values to determine a heart rate value, e.g. bycalculating a time interval separating the first and second R points.

In a related aspect, the invention provides a system for measuring a PTTvalue from a patient that is similar to that described above, butincludes an optical system for measuring a photoplethysmogram from thepatient. This system may be used in place or in addition to theimpedance system. The processing system analyzes photoplethysmogram todetermine a pulsatile component, which it then processes to determinethe PTT value. In general, the system may use any combination ofpulsatile components measured from cardiac rhythm waveforms (e.g., ECGwaveforms), impedance plethysmogram waveforms, and photoplethysmogramwaveforms to determine a PTT value. In embodiments, each system may alsoinclude a weight-measuring system.

In another aspect, the invention features a system for measuring apatient's blood pressure value using PTT, which is measured with theelectrical and mechanical structure described above. The system alsoincludes a pressure-delivery system connected to the structure thatincludes an opening that covers a portion of one of the patient's feetwhen it is in contact with the structure's top surface. Thepressure-delivery system features a flexible member (e.g. a bladder orfoot cuff connected to a pump and valve) configured to apply pressure toa portion of the patient's foot, and a pressure sensor configured tomeasure a first set of signals representative of the applied pressure.The system also includes an optical system connected to the structurethat includes a light source that emits optical radiation, and aphotodetector that receives the optical radiation after it irradiates aportion of the patient's feet to generate a second set of signalsrepresentative of a photoplethysmogram from the patient. A processingsystem in electrical contact with the pressure sensor and optical systemis configured to: 1) receive the first set of signals from thepressure-delivery system and convert them into a set of pressure values;2) receive the second set of signals from the optical system and convertthem into a set of pulsatile signals; and 3) collectively analyze theset of pressure values and the set of pulsatile signals to determine theblood pressure value.

In embodiments, the bladder is formed as a strap, with first and seconddistal ends of the strap connected to the structure's top surface sothat they form an opening that receives air from the pump and/or valve.Computer code in the processing system controls both thepressure-delivery system and the optical system so that the second setof signals representative of a photoplethysmogram are generated whilethe pressure-delivery system applies pressure to the patient's foot. Thecode then analyzes the amplitude and a pressure corresponding to atleast one of the pulsatile signals, ultimately generating a set ofamplitudes corresponding to the set of pulsatile signals, with eachcorresponding to a unique pressure value. To determine blood pressure,the computer code can then determine an amplitude in the set ofamplitudes having a minimum value, and from this estimate SYS. In arelated embodiment, the computer code approximates amplitude values inthe set of amplitudes with a mathematical function, can then estimatesSYS from a minimum value or zero-point crossing of the mathematicalfunction. The computer code can also determine an amplitude having amaximum value from the set of amplitudes (or a mathematical functionapproximating the set of amplitudes), and from this estimate MAP.

As with the other systems described above, the system for measuring ablood pressure value can also feature a weight-measuring system similarto that described above.

In yet another aspect, the invention provides a system for measuring afluid value from a patient. The system features a mechanical structureand weight-measuring system similar to those described above. Toestimate a patient's fluid value, the system includes an electricalimpedance system, similar to that described above, featuring at leastfour electrodes. The electrical impedance system measures a set ofsignals representative of an impedance plethysmogram. A processingsystem in electrical contact with the electrical impedance systemprocesses the signals to determine the fluid value. The electricalimpedance system can measure all the signals from the user's feet, oralternatively may include a hand-held component that features at leasttwo electrodes (one to inject current, the other to measure a signalinduced by the injected current) to contribute to the measurement. Theprocessing system features computer code that, during a measurement,analyzes the set of impedance values to determine the fluid value. Forexample, the computer code can calculate an average of the set ofimpedance values to determine the fluid value.

In addition to providing stand-alone measurements, the floormat may linkwith other devices through its wireless connection to share informationwith the other device in either one or two directions. For example, thefloormat may measure weight, as described above, and then transmit thisinformation to an external sensor which, in turn, may use this value fora separate calculation. An example of a device that links to thefloormat through such a mechanism is the necklace-shaped sensordescribed in the following patent applications, the contents of whichare incorporated herein by reference: “NECK-WORN PHYSIOLOGICAL MONITOR,”U.S. Ser. No. 62/049,279, filed Sep. 11, 2014; “NECKLACE-SHAPEDPHYSIOLOGICAL MONITOR,” U.S. Ser. No. 14/184,616, filed Aug. 21, 2014;and “BODY-WORN SENSOR FOR CHARACTERIZING PATIENTS WITH HEART FAILURE,”U.S. Ser. No. 14/145,253, filed Jul. 3, 2014. In such an arrangement orconfiguration, the necklace-shaped sensor uses the floormat-measuredweight value to calibrate its measurement of SV, since one of thefactors in the equation for SV (δ) is a function of weight. In a similararrangement or configuration, the floormat measures blood pressurevalues (e.g. SYS, DIA, and/or MAP) and transmits these values to thenecklace-shaped sensor, which then uses them to calibrate its cufflessmeasurement of blood pressure. In such cases, for example, the floormatand necklace-shaped sensor suitably communicate through a wirelesstechnology such as Bluetooth® protocols.

The floormat described herein has many advantages. In general, itprovides a single, easy-to-use device that a patient can simply step onto measure all their vital signs, complex hemodynamic parameters, andbasic wellness-related parameters such as weight, percent body fat, andmuscle mass. Such ease of use may increase compliance, therebymotivating patients to use it every day. And with daily use, thefloormat, mobile device, and/or cloud-based system can calculate trendsin a patient's physiological parameters, thereby allowing betterdetection of certain disease states and/or management of chronicconditions such as CHF, diabetes, hypertension, COPD, kidney failure,and/or obesity.

Because of its form-factor/configuration and associated modality of use(i.e., simply stepping onto and standing on it), the floormat helpsensure consistent measurement of the various parameters through thepatient's feet when used on a daily basis, thereby improving therepeatability and reproducibility of its measurements. This isparticularly true given the general similarity of the floormat to aconventional bathroom scale—something most people are used to using on aweekly or even daily basis to determine their health (i.e., weight)status.

Further still, some people—e.g., obese or morbidly obese individuals,for whom various physiological measurements are crucial—can havedifficulty using more conventional sensors. That can be due to thosepatients' size and/or lack of body surfaces that are smooth or “regular”enough to attach electrodes to. Therefore, configuring a physiologicalsensor so that the patient simply needs to stand on it (perhaps withassistance) for accurate measurements to be taken can advantageouslyobviate such issues.

Furthermore, data from the floormat can be combined with data from otherdevices, e.g. wearable devices or other devices within the home, tobetter characterize a patient. For example, one-time measurements fromthe floormat (e.g. resting HR, SV, CO, and/or SYS, DIA, and MAP) can becombined with continuous measurements from the wearable device (e.g.,continuously measured HR and activity levels) to track a patient'sfitness level or progression of a specific disease state. Likewise, datafrom the floormat can be combined with video or still images fromcameras within the patient's home to monitor a patient by collectivelyprocessing physiological information along with that indicating theirat-home activities (e.g., how much they are eating, sleeping, watchingtelevision, etc.). Such information, for example, may indicate the onsetof a physiological condition that may require a medical event, e.g.hospitalization.

Still other advantages should be apparent from the following detaileddescription and from the claims.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a front perspective view of a floormat according to theinvention schematically illustrating its use in monitoring a patient;

FIG. 2A is a rear perspective view of the floormat shown in FIG. 1;

FIG. 2B is a front perspective view of the floormat shown in FIG. 1;

FIG. 3 is a schematic diagram illustrating various sensor subsystemsincluded in the floormat shown in FIG. 1;

FIG. 4A is a front perspective view of the floormat shown in FIG. 1;

FIG. 4B is a schematic section view of FIG. 4A along sight line 4B;

FIG. 4C is a schematic section view of FIG. 4A along sight line 4C;

FIG. 5A is a rear perspective view of the floormat shown in FIG. 1;

FIG. 5B is a plot illustrating a pressure waveform generated by a bloodpressure system within the Floormat of FIG. 1;

FIG. 5C is a plot illustrating a PPG waveform generated by an opticalsystem within the Floormat of FIG. 1;

FIG. 6A is a rear perspective view of the floormat shown in FIG. 1;

FIG. 6B is a schematic circuit diagram illustrating a blood pressuresystem from the floormat of FIG. 6A;

FIG. 6C is a schematic circuit diagram illustrating an optical systemfrom the floormat of FIG. 6A;

FIG. 7A is a rear perspective view of the floormat shown in FIG. 1;

FIG. 7B is a time-dependent plot of an ECG waveform generated with thefloormat of FIG. 7A;

FIG. 7C is a time-dependent plot of a bioimpediance (BI) waveformgenerated with the floormat of FIG. 7A;

FIG. 7D is a time-dependent plot of a derivatized BI waveform of FIG.7C;

FIG. 8A is a rear perspective view of the floormat shown in FIG. 1;

FIG. 8B is a schematic circuit diagram from the floormat of FIG. 8A forgenerating and processing ECG waveforms;

FIG. 8C is a schematic circuit diagram from the floormat of FIG. 8A forgenerating and processing BI waveforms;

FIG. 9 is a set of time-dependent graphs showing (from top to bottom)ECG, BI, PPG, d(BI)/dt, and d(PPG)/dt waveforms;

FIG. 10A is a front perspective view of the floormat shown in FIG. 1;

FIG. 10B is a schematic section view along the sight line 10B in FIG.10A;

FIG. 10C is a schematic representation of the weight-measuring load cellshown in FIG. 10B;

FIG. 10D is a schematic circuit diagram illustrating the WheatstoneBridge used in connection with the load cell of FIG. 10C to measurepatient weight;

FIG. 11A is a schematic diagram illustrating current-flow pathways for afirst configuration of a floormat according to the invention;

FIG. 11B is a schematic diagram illustrating current-flow pathways for asecond configuration of a floormat according to the invention;

FIG. 12A is a perspective view showing an embodiment of the inventionfeaturing a floormat and vertical pole that supports hand-heldelectrodes and a mobile device;

FIG. 12B is a perspective view showing another alternate embodiment ofthe invention featuring a floormat and vertical pole that supportshand-held electrodes and a mobile device;

FIG. 13A is a perspective view showing an embodiment of the inventionfeaturing a floormat and flexible cable that supports hand-heldelectrodes and a mobile device;

FIG. 13B is a perspective view showing yet another an embodiment of theinvention featuring a floormat and flexible cable that supportshand-held electrodes and a mobile device;

FIG. 14A is perspective view showing an alternate embodiment of theinvention featuring a floormat and flexible cable that supportshand-held electrodes;

FIG. 14B is perspective view showing yet another alternate embodiment ofthe invention featuring a floormat and flexible cable that supportshand-held electrodes; and

FIG. 15 is a table showing how parameters measured by the floormat trendwith specific disease states and populations.

DETAILED DESCRIPTION 1. Product Overview

As shown in FIG. 1, the invention provides a stand-on sensor(“floormat”) 100 that measures a number of physiological parameters,e.g. vital signs (e.g. HR, RR, SpO2, SYS, DIA), hemodynamic parameters(CO, SV, TFI), and biometric parameters (weight, percent body fat,muscle mass) of a patient 105. More specifically, the floormat 100measures these parameters from the patient's feet, as is described inmore detail below. In this way, a comprehensive set of physiologicaldata can be measured easily and on a daily basis while the patient 105simply stands on the floormat 100, in a manner that is similar to howthe patient would use a standard bathroom scale to weigh himself orherself.

Once the physiological information is obtained, the floormat 100wirelessly transmits it, e.g., using a short-range wireless technology(suitably Bluetooth® wireless technology) to a mobile device 90, e.g., aconventional smartphone or tablet computer belonging to the patient. Insome embodiments, the floormat 100 may lack any display to render agraphical user interface (GUI) and may rely instead strictly on themobile device 90 for this functionality, which somewhat simplifiesoverall construction of the floormat. For example, the GUI could berendered on the mobile device 90 with a downloadable softwareapplication that operates on standard mobile operating systems, e.g.,Android or iOS operating systems. During use, the GUI can prompt thepatient 105 to step on the floormat 100; display the various informationthat it measures; plot trends in numerical values; graph time-dependentwaveforms; provide other content related to the floormat-measuredinformation; and provide content/information on how to improve thepatient's health. It should be appreciated, however, that embodiments ofa floormat that do include some form of display are, of course, deemedto be within the scope of the invention.

After the mobile device 90 receives information from the floormat 100,it transmits the information using a long-range wirelesstechnology—suitably based on 802.11b/g/n, i.e. WiFi®, or cellularsystems such as those provided by ATT, Cingular, TMobile, etc.—to acloud-based analytics platform 80. This can be, for example, a softwaresystem associated with, e.g., an Internet browser, electronic medicalrecord (EMR), database, and/or website. The cloud-based analyticsplatform 80 suitably features GUIs for both the patient and clinicians.Suitably, the patient GUI renders only the patient's information,whereas the clinician's GUI renders information collected from a groupof patients. Like the GUI on the mobile device 90, the cloud-basedanalytics platform GUI renders the information; plots trends in specificparameters; and, in general, allows a remote clinician to monitor thepatient 105 in their home environment.

As illustrated in FIGS. 2A, 2B, and 3, the floormat 100 includes thefollowing features or subsystems for characterizing the patient: i) animpedance system 50; ii) an ECG system 51; iii) an optical system 52;iv) a blood pressure system 53; v) a weight system 54; and vi) a digitalprocessing system 55. Together, these systems measure and process theabove-described physiological information and send it to the mobiledevice and cloud-based analytics platform for further analysis. Thesesystems 50-55 are integrated within the floormat 100, which provides asimple, easy-to-use device that resembles a conventionalweight-measuring scale.

More particularly, the blood pressure system 53 includes back and frontstraps 101, 103 that form a pocket to receive, for example, thepatient's left foot. In other embodiments, however, the straps could bepositioned to form a pocket to receive the patient's right foot instead.The straps 101, 103 resemble those present in conventional sandals orbathroom slippers. The back strap 101 includes an inflatable airbladder, described in more detail below, which is coupled to apressure-delivery system 115. During a measurement, the air bladder andhence the strap 101 inflates and gently constricts blood flow in thepatient's foot.

An optical system 120 is housed within or mounted to the front strap 103in position to face the upper surface of the patient's foot when thepatient places his or her foot into the pocket formed by the straps. Theoptical system 120 measures blood flow and corresponding PPG waveformsfrom the left foot while pressure is being applied to it, and in thisway provides inputs that are used in the blood pressure analysis, as isdescribed in more detail below.

An upper, top layer of material 102, which is suitably composed ofsilicone rubber, provides a soft, comfortable, non-slip surface for thepatient to stand on. The soft, silicone top layer 102 extends over mostof the top surface of the floormat 100 and supports the patient's left105 a and right 105 b feet during a measurement. Rigid side panels 127,which may be part of a surrounding framework that forms a base for thefloormat 100, surround the top surface 102 and help stabilize thefloormat 100 when the patient 105 stands on it. The base, of course,should be strong enough to support the weight of an adult patient, e.g.,someone weighing up to 350 pounds (or more, perhaps, for use in moreclinical healthcare facilities such as obesity-treatment centers). Foursupport posts (two of which 104 a, 104 b are shown in the figure) extendfrom a bottom surface 106 of the floormat, allowing the floormat 100 torest on a horizontal surface, e.g. a floor. Suitably, the support postsare individually adjustable, e.g., by screwing or unscrewing them intoor out of the bottom surface 106 of the floormat 100, so as to level thefloormat 100.

A conventional weight-measurement system that uses a Wheatstone Bridge,illustrated and described below in connection with FIG. 10, is locatedbeneath the top layer 102. The weight-measurement system measures signalinputs from strain gauges within the floormat, described in more detailbelow, to determine the patient's weight.

Four conductive stainless steel electrodes 129 a, 129 b, 130 a, 130 bare partially embedded within the top layer of material 102, with uppersurfaces of the electrodes exposed so as to make contact with the solesof the patient's feet when the patient stands on the floormat. Theelectrodes are used to measure electrical signals from the patient'sleft and right feet simultaneously, which signals are amplified andfiltered by circuits on the circuit board 117 to generate BI and ECGwaveforms as well as bioreactance impedance signals, the latter of whichare used to determine percent body fat and muscle mass. (BI is animpedance waveform that is analogous to TBI, except it is not obtainedexclusively from the patient's chest, and therefore does not referencethe thorax via a “T” in its acronym.) While stainless steel is apreferred material for the electrodes, other materials may also be used.These include conductive rubber, conductive fabrics, metals other thanstainless steel, and materials coated with conductive materials, such asfilms of Ag/AgCl.

An electronics module 125, which may be housed within a forward portionof the top layer 102, includes all of the electronics for the impedance50, ECG 51, optical 52, blood pressure 53, weight 54, and digital 55systems. These systems generally include a number of analog amplifiersand filters, which are described in detail in the following co-pendingpatent applications entitled “NECK-WORN PHYSIOLOGICAL MONITOR,” U.S.Ser. No. 62/049,279, filed Sep. 11, 2014; “NECKLACE-SHAPED PHYSIOLOGICALMONITOR,” U.S. Ser. No. 14/184,616, filed Aug. 21, 2014; and “BODY-WORNSENSOR FOR CHARACTERIZING PATIENTS WITH HEART FAILURE,” U.S. Ser. No.14/145,253, filed Jul. 3, 2014, all three of which were incorporated byreference above. The digital processing system 55 within the electronicsmodule 125 digitizes the analog waveforms generated by impedance 50, ECG51, optical 52, blood pressure 53, and weight 54 systems, and thenprocesses the digitized waveforms using a number of algorithms operatingon a microprocessor, as is described in more detail below.

FIGS. 4A-C respectively show a three-dimensional perspective view of thefloormat 100 with a patient standing on it. Section views (FIGS. 4B, 4C)better illustrate the back strap 101 and the front strap 103, whichcover corresponding portions of the patient's left foot 105 a when thepatient is using the floormat 100 to measure his or her variousphysiological parameters.

To measure blood pressure (e.g. SYS and DIA), a diaphragm pump 109 pumpsair through a controllable valve 111 and into bladder 107 via a flexibletube 113. The bladder 107 may be provided as a separate bladder “bag”that fits within a pocket in the back strap 101, or it may be formedsimply as an airtight chamber within the back strap 101 itself. Apressure sensor 110 that is in fluid (i.e., air) communication with theflexible tube 113 senses pressure within the bladder 107. Collectively,the pump 109, valve 111, and flexible tube 113 form a pressure-deliverysystem 115 that pumps air into the inflatable bladder 107, therebycausing it to constrict around the patient's left foot 105 a; after airinside the bladder reaches a pre-determined pressure, the valve 111slowly releases pressure. During inflation or deflation, the pressuresensor 110 measures the resultant pressure within the system.

A circuit board 117 with a programmable microprocessor 119 controlsoperation of the pressure-delivery system 115. Typically, such “control”means switching on and off a transistor (e.g. a field-effect transistor,or FET, not shown in the figure), which causes a voltage (e.g. 5V) to beprovided to or removed from the pump 109 and valve 111. Such voltageopens the valve 111 and powers the pump 109, thereby causing it to pumpair through the flexible tube 113 and into the bladder 107 to cause thebladder to expand. As the bladder 107 expands, the space inside the rearstrap 101 contracts around the bridge of the patient's left foot,thereby constricting blood flow (which is a requirement for measuringblood pressure in this manner, as described in more detail below).

The front strap 103, on the other hand, is positioned to cover a frontportion of the patient's left foot 105 a and includes theabove-referenced optical system 120. The optical system 120 includes alight source 122 and a photodetector 124 that are used to generate a PPGwaveform from the top of the patient's foot. The light source 122 may bea light-emitting diode (LED), and the photodetector may be a standardPIN photodetector. During a measurement, the light source 122 emitsoptical radiation, alternating between red (about 660 nm) and infrared(about 905 nm) wavelengths, to irradiate blood vessels in the frontportion of the left foot 105 a. Typically with such systems, theradiation propagates a few hundred microns into blood vessels on thefoot's outer surface, where it irradiates the vessels and partiallyreflects back towards the photodetector.

As dictated by Beer's law, which describes the basic premise of opticalabsorption through a volumetric sample, the reflected radiation willvary in intensity as blood pulses through the vessels and causes them toexpand and contract periodically, thus causing the reflected radiation'sintensity to modulate. The reflected radiation, in turn, irradiates thephotodetector 124, which, in response to the sensed reflected radiation,generates a proportional, modulated photo-induced current that passesthrough a thin cable 126 to the circuit board 117, where it is amplifiedand filtered to generate the PPG waveform.

With the physical structure of the floormat 100 in mind, its methods toacquire and process the pressure, PPG, BI, and ECG waveforms, andthereby determine vital signs and hemodynamic parameters, are describedin more detail below.

2. Blood Pressure Measurement

To measure blood pressure, e.g., as part of an overall physiological“reading,” the pressure-delivery system and the optical systemsimultaneously measure pressure and blood pulsation and generatetime-dependent pressure and PPG waveforms 150, 152 as illustrated inFIGS. 5B and 5C, respectively. These waveforms can be analyzed as thebladder deflates, as is illustrated in the figures. In this case, theoptical pulsation in the PPG waveform gradually reappears as thepressure drops below SYS. Alternatively, the waveforms can be measuredas the bladder inflates. Here, the pulsation in the waveform graduallydiminishes as the pressure approaches SYS. In either case, themicroprocessor processes these waveforms with a mathematical model toidentify a specific pressure corresponding to the disappearance-point(or reappearance-point) of heartbeat-induced pulsation in the PPGwaveform 152.

More specifically, the model assumes that pressure applied by thebladder compresses the arteries in the patient's foot, thereby at leastpartially occluding blood flow in the arteries. This, in turn, causesthe heartbeat-induced pulsation in the PPG waveform to graduallydecrease in amplitude during pressurization of the bladder until it (thepulsation) eventually becomes undetectable or, alternatively, toincrease in amplitude (if measurement is made during depressurization ofthe bladder) until it becomes detectable. The pressure being applied tothe patient's foot at the moment when pulsation reappears or disappears,as the case may be, corresponds to SYS. A conventional peak-detectingalgorithm executing on the microprocessor can be used to detect theonset or cessation of the pulse amplitude in the PPG waveform toidentify this “breakpoint;” correlating the breakpoint with the pressurewaveform 150 allows the system to make a direct measurement of SYS.

Alternatively, a “fitting” algorithm can be used to model the systematicdecrease in pulse amplitude with applied pressure with a mathematicalfunction (e.g. a linear or polynomial function) featuring parametersthat are iteratively varied, with the parameters providing the closestapproximation to the measured PPG waveform being used to estimate SYS.This latter technique may be used to estimate SYS fairly quickly.

In still other alternative embodiments, pulsations in the pressurewaveform caused by heartbeat-induced blood flow in the patient's footcan be analyzed as is done in conventional oscillometry (i.e. thestandard technique for automated blood pressure-monitoring systems).Typically, in this case, algorithms process the pressure-dependentamplitude in the pulsations, which are extracted from the pressurewaveform with hardware or software filters to remove the DC background.This typically results in a bell-shaped curve from which MAP(corresponding to the curve's maximum point), DIA (extracted from therelatively low-pressure side of the curve), and SYS (extracted from therelatively high-pressure side of the curve) are determined.

Referring back to FIG. 5, when pressure applied by the air bladder isroughly equal to the mean pressure within the underlying blood vessel—acondition that causes the heartbeat-induced pulsations to distort thevessels so that their volumetric change is maximized—the pulse amplitudewill be maximized. This maximization of the pulse amplitude can, inturn, be detected and therefore used to approximate MAP. Subsequently,DIA is calculated from SYS, MAP (as so approximated), and pulse pressure(PP) using to Eqs. 9 and 10, below.

MAP≈DIA+⅓×PP  (9)

PP=SYS−DIA  (10)

Suitable circuits 160 and 170 to control operation of thepressure-delivery system and the optical system, which work together tomeasure blood pressure as described above, are illustrated in FIGS. 6Band 6C, respectively.

3. Pulse Oximetry Measurements

In addition to being used to identify the pressure point at whichpulsation reappears or disappears as pressure in the air bladder isdecreased or increased, respectively, so as to identify SYS, the opticalsystem and its associated electrical circuit 170 are also used todetermine pulse oximetry. PPG waveforms generated during thismeasurement will be similar to those shown in FIG. 5C, only they aremeasured in the absence of any applied pressure. Thus waveforms for thismeasurement typically pulsations featuring a relatively constantamplitude.

In general, PPG waveforms are generated using red and infraredradiation. More particularly, the floormat's digital system controls thepulse oximetry circuit 170 so that LEDs 120 (FIG. 4C) operating at redand infrared wavelengths are powered on and off in an alternatingfashion. The associated photodetector 124 senses radiation signalsreflected from the patient's foot and processes them via the circuit 170as described below to generate the PPG waveforms.

Thus, during a pulse oximetry measurement, the LEDs alternatingly emitbeams of radiation near 660 nm and 905 nm and at approximately 500 Hz.The beams of radiation pass through portions of the foot and rapidlydiverge and scatter off of tissue/structures such as skin, bone, andcapillaries near the outer surface of the foot before reaching thephotodetector. Blood in the capillaries pulsates with each heartbeat andabsorbs radiation emitted by the LEDs. This results in separate,time-dependent optical waveforms, i.e., RED/IR(PPG), for each of the 660nm and the 905 nm radiation. Both waveforms include AC componentscorresponding to the time-dependent pulsation of the blood and DCcomponents corresponding to time-independent scattering of the radiationoff of the skin, bone, and non-pulsating components of the capillaries.Prior to any filtering, the AC component of each signal typicallyrepresents about 0.5-1% of the total signal.

Collectively processing the AC and DC signals of the RED/IR(PPG)waveforms allows one to obtain an SpO2 value, and the microprocessorwithin the floormat uses a number of signal-processing methodologies todo so. Ultimately, the AC and DC components yield a so-called “ratio ofratios” (RoR), which can be related to an SpO2 value through a series ofempirically determined coefficients.

In one embodiment of a floormat according to the invention, for example,the RoR is determined by first measuring RED/IR(PPG) waveforms and thenpassing them through a low-pass filter characterized by a 20 Hz cutoff.The averaged baseline component of each waveform is sampled and storedin memory and represents RED/IR(DC). Both waveforms are additionallyfiltered with a high-pass filter having a 0.1 Hz cutofffrequency—typically implemented with a finite impulse responsefunction—and finally amplified with a variable gain amplifier. Thesesteps can be implemented with either digital software filters or analogfilters integrated into the pulse oximetry circuit 170. Signalcomponents passing through this filter are isolated to yield RED/IR(AC).Once they have been so isolated or extracted, the AC and DC signals areprocessed to yield a RoR value, described in Eq. 11, which relates toSpO2 as follows:

$\begin{matrix}{{R\; o\; R} = \frac{{RED}\mspace{14mu} {({AC})/{RED}}\mspace{14mu} ({DC})}{I\; {{R({AC})}/I}\; {R({DC})}}} & (11)\end{matrix}$

An SpO2 value is calculated from Eq. 12, below. Here, coefficients a, b,and c for this calculation are determined beforehand, e.g., by fittingempirical data to a corresponding mathematical function. In oneembodiment, coefficients a, b, and c have values, respectively, of 107,−3, and −20.

SpO2=(a+b*RoR+c*RoR²)×100  (12)

The exact values of these parameters will depend on and vary with thespecific wavelengths of the LEDs used in the pulse oximeter probe. Thisis because the SpO2 measurement is fundamentally determined by therelative optical absorption of hemoglobin (Hb) and oxygenated hemoglobin(HbO2) in the red and infrared spectral regions, and absorption, inturn, depends on the specific wavelength emitted by a given LED. Theabsorption spectra of Hb and HbO2 are relatively flat in the infraredspectral region, but strongly divergent in the red spectral region. Thecoefficients a, b, and c are thus relatively sensitive to the exactwavelength of the red LED. Therefore, prior to manufacturing, a seriesof empirical studies should be performed using pulse oximeter probeswith LEDs that emit radiation of varying wavelengths surrounding the redemission wavelength (e.g. 600-610 nm). A typical example of such a studyis called a “breathe-down” study because it involves lowering the SpO2values of a series of patients (typically about 10-15) under medicalsupervision. In a breathe-down study, SpO2 is typically lowered bydecreasing the amount of oxygen each patient inhales through aspecialized ventilator mask; this is often done in a room with a reducedtemperature. Blood from the patients is aspirated from an arterial lineand analyzed with a blood gas analyzer to determine its oxygen content.Simultaneously, a pulse oximeter probe with known LED wavelengths isattached to each patient—in this case near the feet—and is used tomeasure the RoR as described in Eq. 11 above. SpO2 values for thisexperiment, as measured with the blood gas analyzer, typically rangefrom 70-100%. Simultaneous studies are typically done using pulseoximeter probes having LEDs with different red emission spectra. Uponcompletion of the studies, the wavelength-dependent values of RoR arerelated to SpO2, as determined by the blood gas analyzer, to calculatecoefficients a, b, and c as described above. In general, a different setof coefficients will result for the different LED wavelengths. Thesecoefficients and the optical wavelengths they correspond to, along witha resistor value described below, are stored in a database in memory onthe floormat.

4. Stroke Volume, Cardiac Output, and Fluid Measurements

FIGS. 7A-D and 8A-C illustrate in more detail components of the floormatthat enable it to measure and generate the patient's BI waveforms and toderive CO/SV values therefrom. As indicated above, two sets of stainlesssteel electrodes 175 a (for the left foot) and 175 b (for the rightfoot) measure electrical signals at the bottoms of the patient's feet.During a measurement, an impedance circuit 220 (FIG. 8C) injectshigh-frequency, low-amperage current (I) through the rear, “heelelectrodes” 130 a, 130 b (see FIGS. 2A and 2B), which are positioned tomake contact with the bottoms of the patient's left and right heels whenhe or she stands on the floormat. Suitably, the modulation frequency maybe about 70-100 kHz, and the current may be about 4-10 mA. Furthermore,the current injected by one electrode is out of phase by 180° withrespect to the current injected by the other electrode.

Circuitry within the floormat is configured such that the currentinjected by each heel electrode flows up the corresponding leg, throughthe patient's abdomen/thorax, down the other leg, and to the oppositefoot. As the current flows, it scatters off the tissue it propagatesthrough, and encounters static (i.e. time-independent) resistance frombody components such as bone, skin, and other tissue in the patient'slower extremities. Additionally, blood conducts current to some extent;therefore, blood ejected from the left ventricle of the heart and intothe aorta provides a dynamic (i.e. time-dependent) component ofelectrical conductivity and, consequently, electrical resistance. Theaorta is the largest artery passing blood out of the heart, and thus ithas a dominant impact on the dynamic resistance; other vessels, such asthe superior vena cava, will contribute in a minimal way to the dynamicresistance.

Forward electrodes 129 a, 129 b (see FIGS. 2A and 2B), on the otherhand, are positioned so as to contact the balls of the patient's leftand right feet, respectively, when the patient stands on the floormat.These forward electrodes sense, and hence measure, a time-dependentvoltage (V) that varies with the resistance (R) encountered by theinjected current I according to Ohm's Law (V=I×R). During a measurement,the time-dependent voltage sensed by the forward electrodes is amplifiedand filtered by the impedance circuit 220 and ultimately processed withan analog-to-digital converter in the electronics module.

Two further waveforms can be extracted from the BI waveform. The firstwaveform 180 (FIG. 7C) exhibits relatively high-frequency variationscaused by heartbeat-induced impedance changes measured by the BI system.This represents the AC component of the BI bioimpedance waveform.Furthermore, the mathematical derivative of the AC component of the BIwaveform (plot 182, FIG. 7D) can be processed with a first algorithm todetermine (dZ(t)/d(t))_(max) and left ventricular ejection time (LVET).(As used herein, d(Z(t))/dt and d(BI(t)/d(t) are considered to beequivalent.) A separate waveform—not shown in the figure but exhibitingrelatively low-frequency variations in impedance—can be processed with asecond algorithm to determine Z₀. These threeparameters—(dZ(t)/d(t))_(max), LVET, and Z₀—are then processed tocalculate SV using an equation such as that shown in Eq. 13, which isSramek-Bernstein equation, or a mathematical variation thereof.

$\begin{matrix}{{S\; V} = {\delta \frac{L^{3}}{4.25}\frac{( {{{dZ}(t)}/{dt}} )_{\max}}{Z_{0}}L\; V\; E\; T}} & (13)\end{matrix}$

In Eq. 13, the term “Z(t)” represents the AC component of a conventionalimpedance waveform. According to the invention described herein, Z(t) isreplaced with the AC component of the BI waveform. δ representscompensation for body mass index, which may be determined using thefloormat's weight scale component, as described in more detail below. Z₀is a base impedance value estimated from the DC component of the BIwaveform. L is estimated from the distance separating respectivecurrent-injecting and voltage-measuring electrodes, and can beapproximated from the patient's height.

Alternatively, waveforms measured with the impedance system can beprocessed with an algorithm based on Eqs. 5 and 6, above.

And LVET, as described above, is the left ventricular ejection time,which is preferably determined from the BI waveform, or alternativelyfrom the HR using an equation called “Weissler's Regression,” shownbelow in Eq. 14, which estimates LVET from HR:

LVET=−0.0017×HR+0.413  (14)

Weissler's Regression allows LVET to be estimated from HR as determinedfrom the ECG waveform. This equation and several mathematicalderivatives, along with the parameters shown in Eq. 13, are described indetail in the following reference, the contents of which areincorporated herein by reference: Bernstein, Impedance cardiography:Pulsatile blood flow and the biophysical and electrodynamic basis forthe stroke volume equations; J Electr Bioimp; 1: 2-17 (2010). Both theSramek-Bernstein Equation and an earlier derivative of it, called theKubicek Equation, feature a “static component” Z₀ and a “dynamiccomponent” ΔZ(t), which relates to LVET, and a (dZ/dt)_(max)/Z₀ value,calculated from the derivative of the raw bioimpedance signal, ΔZ(t).(These equations assume that (dZ(t)/dt)_(max)/Z₀ represents a radialvelocity (with units of Ws) of blood due to volume expansion of theaorta.)

Additionally, the same electrodes used to measure the impedancewaveforms BI can also be used to measure standard ECG waveforms, whichare illustrated in the plot 183 (FIG. 7B). Associated electricalcircuitry 230 used to determine the ECG waveform is illustrated in FIG.8B. From this waveform, HR can be estimated from the inverse of the RRinterval, as indicated on the plot 183.

5. Pulse Transit Time Measurements

Pulse transit times are timing-related parameters that can be extractedfrom the physiological waveforms described above. They are known tocorrelate inversely to blood pressure and, additionally, may indicatethe compliance (and thus stiffness) of the patient's arteries. Incertain embodiments, the floormat can measure pulse transit times, asexplained in more detail below, and then use these parameters toestimate blood pressure without using a pressure-delivery system likethe one described above. Additionally, pulse transit times, combinedwith blood pressure values determined using the pressure-deliverysystem, may be used to estimate changes in the patient's arterialcompliance. One technique for making such an estimation is described indetail in the following reference, the contents of which areincorporated herein by reference: “Vital sign monitor for cufflesslymeasuring blood pressure corrected for vascular index,” Publicationnumber WO2008154647, filed Jun. 12, 2008.

FIG. 9, for example, shows the following time-dependent waveforms, asmeasured by the floormat: ECG (plot 200), BI (plot 202), PPG (plot 204),d(BI)/dt (plot 206), and d(PPG)/dt (plot 208). As shown in plots 200 and202, individual heartbeats produce time-dependent pulses in both the ECGand BI waveforms. As is clear from the data, pulses in the ECG waveformprecede those in the BI waveform. The ECG pulses—each featuring a sharp,rapidly rising QRS complex—indicate initial electrical activity incontractions in the patient's heart and, informally, the beginning ofthe cardiac cycle.

BI pulses follow the QRS complex by about 100 ms and indicate blood flowthrough arteries in the region of the body where the electrodes makecontact with the skin. During a heartbeat, blood flows from thepatient's left ventricle into the aorta; the volume of blood that leavesthe ventricle is the SV. Blood flow periodically enlarges this vessel,which is typically very flexible, and also temporarily aligns bloodcells (called erythrocytes) from their normally random orientation. Boththe temporary enlargement of the vessel and alignment of theerythrocytes improves blood-based electrical conduction, thus decreasingthe electrical impedance as measured with BI. The d(BI)/dt waveform(plot 206) shown in FIG. 9 is a first mathematical derivative of the rawBI waveform, meaning its peak represents the point of maximum impedancechange.

A variety of time-dependent parameters can be extracted from the ECG andBI waveforms. For example, as noted above and indicated in FIG. 7B, itis well know that HR can be determined from the time separatingneighboring ECG QRS complexes. Likewise, LVET can be measured directlyfrom the derivative of the BI pulse, as shown in FIG. 7D, and isdetermined from the onset of the derivatized pulse to the firstpositive-going zero crossing. Also measured from the derivatized BIpulse is (dBI/dt)_(max), which is a parameter used to calculate SV asdescribed above.

The time difference between the ECG QRS complex and the peak of thederivatized BI waveform represents a pulse arrival time PAT, asindicated in FIG. 9. This value can be calculated from other fiducialpoints, including, in particular, locations on the BI waveform such asthe base, midway point, or maximum of the heartbeat-induced pulse.Typically, the maximum of the derivatized waveform is used to calculatePAT, as it is relatively easy to develop a software beat-pickingalgorithm that finds this fiducial point.

PAT correlates inversely to SYS and DIA, as shown below in Eqs. 15 and16, where m_(SYS) and m_(DIA) are patient-specific slopes for SYS andDIA, respectively, and SYS_(cal) and DIA_(cal) are values of SYS andDIA, respectively, measured during a calibration measurement. (Such ameasurement can, for example, be performed with the pressure-deliveryand optical systems described above.) Without the calibration, PAT onlyindicates relative changes in SYS and DIA. The calibration yields boththe patient's immediate values of SYS and DIA. Multiple values of PATand blood pressure can be collected and analyzed to determinepatient-specific slopes m_(SYS) and m_(DIA), which relate changes in PATwith changes in SYS and DIA. The patient-specific slopes can also bedetermined using pre-determined values from a clinical study, and thencombining these measurements with biometric parameters (e.g. age,gender, height, weight) collected during the clinical study.

$\begin{matrix}{{SYS} = {\frac{m_{SYS}}{P\; A\; T} + {SYS}_{cal}}} & (15) \\{{DIA} = {\frac{m_{DIA}}{P\; A\; T} + {DIA}_{cal}}} & (16)\end{matrix}$

In embodiments of the floormat, waveforms like those shown in FIG. 9 canbe processed to determine PAT. This parameter, combined with acalibration determined as described above, can be used by the floormatto determine blood pressure without a physical-pressure-applyingmechanism via Eqs. 15 and 16, above. Typically PAT and SYS correlatebetter than PAT and DIA, and thus this parameter is first determinedusing Eq. 15. In one embodiment, DIA is then determined using Eq. 16.Alternatively, PP can be estimated from SV, as described below, and thenused with SYS to determine DIA according to, e.g. Eqs. 5 or 6, above.

PP can be estimated from either the absolute value of SV, SV modified byanother property (e.g. LVET), or the change in SV. In the first method,a simple linear model is used to process SV (or, alternatively, SV×LVET)and convert it into PP. The model uses the instant values of PP and SV,determined as described above from a calibration measurement, along witha slope that relates PP and SV (or SV×LVET) to each other. The slope canbe estimated from a universal model that, in turn, is determined using apopulation study.

Alternatively, a slope tailored to the individual patient can be used.Such a slope can be selected, for example, using biometric parametersdescribing the patient as described above.

Here, PP/SV slopes corresponding to such biometric parameters aredetermined from a large population study and then stored in computermemory on the floormat. When a floormat is assigned to a patient, theirbiometric data is entered into the system, e.g. using a GUI operating onmobile telephone, that transmits the data to a microprocessor in thefloormat via Bluetooth®. Then, an algorithm on the floormat processesthe data and selects a patient-specific slope. Calculation of PP from SVis explained in the following reference, the contents of which areincorporated herein by reference: “Pressure-Flow Studies in Man. AnEvaluation of the Duration of the Phases of Systole,” Harley et al.,Journal of Clinical Investigation, Vol. 48, p. 895-905, 1969. Asexplained in this reference, the relationship between PP and SV for agiven patient typically has a correlation coefficient r that is greaterthan 0.9, which indicates excellent agreement between these twoproperties. Similarly, in the above-mentioned reference, SV is shown tocorrelate with the product of PP and LVET, with most patients showing anr value of greater than 0.93 and the pooled correlation value (i.e., thecorrelation value for all subjects) being 0.77. This last valueindicates that a single linear relationship between PP, SV, and LVET mayhold for all patients.

More preferably, PP is determined from SV using relative changes inthese values. Typically, the relationship between the change in SV andchange in PP is relatively constant across all subjects. Thus, similarto the case for PP, SV, and LVET, a single, linear relationship can beused to relate changes in SV and changes in PP. Such a relationship isdescribed in the following reference, the contents of which areincorporated herein by reference: “Pulse pressure variation and strokevolume variation during increased intra-abdominal pressure: anexperimental study,” Didier et al., Critical Care, Vol. 15:R33, p. 1-9,2011. Here, the relationship between PP variation and SV variation for67 subjects displayed a linear correlation of r=0.93, which is anextremely high value for pooled results that indicates a single, linearrelationship may hold for all patients.

From such a relationship, PP can be determined from the BI-based SVmeasurement, and SYS can be determined from PAT. DIA can then becalculated from SYS and PP.

The floormat determines RR from the DC BI waveform, described above. Inthis case, the patient's respiratory effort moves air in and out of thelungs, thus changing the impedance in the thoracic cavity. Thistime-dependent change maps onto the BI waveform, typically in the formof oscillations or pulses that occur at a much lower frequency than theheartbeat-induced cardiac pulses shown in the upper part of FIG. 10.Simple signal processing (e.g. filtering, beat-picking) of thelow-frequency, breathing-induced pulses in the waveform yields RR.

Another parameter, called vascular transit time (VTT), can be determinedfrom pulsatile components in the BI (or d(BI)/dt) waveform and the PPG(or d(PPG)/dt) waveform. FIG. 9 shows in more detail how VTT isdetermined. It can be used in place of PAT to determine blood pressure,as described above. Using VTT instead of PAT in this capacity offerscertain advantages, namely, lack of signal artifacts such aspre-injection period (PEP) and isovolumic contraction time (ICT), whichcontribute components to the PAT value but which are not necessarilysensitive to or indicative of blood pressure.

6. Weight, Percent Body Fat, and Muscle Mass Measurement

In addition to the vital signs and hemodynamic parameters describedabove, the floormat also measures biometric parameters such as weight,percentage body fat, and muscle mass (also known as skeletal muscle).Weight is measured using a relatively conventional scale mechanismwithin the floormat. As illustrated in FIGS. 10A-D, for example,embodiments of the floormat 100 include a stabilizing bar 150 with oneor more load cells 148 attached to it to measure the patient's weight.The stabilizing bar 150, which may have holes 154 extending through it(FIG. 10C) to reduce its rigidity and allow it to flex/induce strainwhen a patient stands on the floormat, is suitably disposed on thefloormat's bottom surface and connected to the supporting posts 104 a,104 b at its distal ends. In some embodiments of the floormat, thefloormat 100 may have two stabilizing bars, with one stabilizing bar (asillustrated) being connected to supporting posts 104 a, 104 b on oneside of the floormat and the other stabilizing bare (not illustrated)being connected to supporting posts (also not illustrated) located atthe floormat's opposite corners. In the illustrated embodiment, the twostabilizing bars are parallel to each other; in alternate embodiments ofthe floormat, they may intersect with each in a criss-cross pattern.

As further illustrated in the figures, load cell 148 is located near themid-point of the stabilizing bar and is integrated directly into thestabilizing bar, and a pair of strain gauges 151, 152 are connected toopposite surfaces of the stabilizing bar 150 to form the load cell 148portion of the stabilizing bar. In one embodiment of the floormat, thestrain gauges may be flexible circuits with a serpentine pattern ofconductive traces having a resistance value that varies with strain.When the patient stands on the floormat, the stabilizing bar flexes orbows; depending on the specific manner in which the stabilizing bar ismounted and supported within the base of the floormat, it will boweither upwardly (concavity-down) or downwardly (concavity-up). With suchflexing of the stabilizing bar, the strain gauge located on the “inside”surface of the bow will be compressed, while the strain gauge located onthe “outside” surface of the bow will be extended. Both compression andextension of the strain gages cause slight changes in the strain gauges'resistance values—one change being a decrease in resistance and theother change being an increase in resistance—and such variation inresistance can be measured and used to determine the amount by which thestabilizing bar flexes and, hence, the weight being applied to it.

In alternate embodiments, the strain gauges shown in FIG. 10 can bedisposed in other locations within the floormat. In one alternateconfiguration, for example, they are disposed in the floormat's supportposts 104 a, 104 b, and configured so that a patient standing on thefloormat causes them to compress and extend, as described above.

In total, the illustrated embodiment of a floormat according to theinvention has two load cells—one for each stabilizing bar—and thus fourstrain gauges. As illustrated in FIG. 10D, each of the strain gaugesforms an arm of an electrical circuit 160 featuring a four-resistorcircuit component (i.e., a Wheatstone Bridge 162) that, when connectedto an amplifier circuit 164, can be used to determine the patient'sweight.

During a measurement, the patient stands on the top surface 102 of thefloormat 100. The force associated with the patient's weight affects thestrain gauges, resulting in small resistance changes that are amplifiedby the Wheatstone Bridge 162, causing it to produce an output voltage.The output voltage is further amplified by the amplifier circuit 164,thus resulting in an input voltage to an analog-to-digital converterthat varies with weight. (Gain resistor RG determines the degree ofamplification in the amplifier circuit 164.) The system can becalibrated by placing weights of known values on the floormat's surfaceand then measuring the resulting voltages that are input to theanalog-to-digital converter. Once the load-cell system has beencalibrated, the floormat can measure the patient's weight.

The floormat complements this weight measurement by estimating thepatient's percent body fat and muscle mass. This measurement isimplemented with the four stainless steel electrodes 129 a, 129 b, 130a, and 130 b (see, e.g., FIGS. 2A and 2B) that contact the soles of thepatient's feet. More specifically, as addressed above, these electrodesmeasure electrical signals to generate electrical impedance waveforms Z₀and ΔZ(t). Z₀, in particular, is an input into Eq. 16, below, and isused to determine percentage of body fat. Additionally, the floormat mayinclude another circuit that measures a parameter called bio-reactance(Xc), which is also used as an input in Eq. 16. (Bio-reactance refers tothe electrical resistive, capacitive, and inductive properties of bloodand biological tissue that induce phase shifts between an appliedelectrical current and the resulting voltage signal. This parameter isdistinguished from bioimpedance, addressed above, which refers to theelectrical properties of blood and tissue that determine the amplitudeof the voltage field resulting from an applied electrical current.)

During a measurement, the stainless steel electrodes measure electricalsignals that are processed with circuitry in the floormat to determineZ₀ (from the bioimpedance measurement used to sense BI waveforms) and Xc(from the bioreactance measurement, described above). These parametersare used in Eq. 16, below, along with the patient's weight as measuredby the weight-measuring system, to estimate the patient's fat-free mass(FFM), which can be used as an estimate of muscle mass:

FFM (kg)=a×(height² /Z ₀)+b×(weight)−c×(age)+d×X _(c))−e  (16)

where a, b, c, and d are constants determined from a clinical study, asfollows: a=0.7374, b=0.1763, c=0.1773, d=0.1198, and e=2.4658. Eq. 11,along with the constants used to estimate FFM, are described in detailin the following reference, the contents of which are incorporatedherein by reference: Macias et al., Body fat measurement bybioelectrical impedance and air displacement plethysmography: across-validation study to design bioelectrical impedance equations inMexican adults; Nutrition Journal; 6: (2007). Subtracting FFM from bodyweight, and then dividing this number by the body weight, is used toestimate the patient's percentage of body fat.

7. Electrode Placement and Impedance Measurements with the Floormat

In the floormat embodiments described so far, all four electrodes—i.e.,the two current-injecting electrodes and the twocurrent-receiving/voltage-sensing electrodes—are arranged on the uppersurface of the floormat so that all skin-to-electrode contact occurs onthe soles of the patient's feet and current flows from one foot to theother in connection with the BI measurement. As noted above, however, inalternate embodiments of the floormat, a handheld electrode unit(featuring two electrodes) can be provided in addition to or instead ofone of the foot-contacting electrode pairs, so that current flowsbetween one of the feet and one of the hands. The current-flow pathwayfor each such configuration is illustrated in FIGS. 11A and 11B.

Thus, as shown in FIG. 11A for a foot-to-foot configuration of thefloormat, electrode pairs 252, 254—each pair including acurrent-injecting electrode (I₁, I₂) and a voltage-sensing electrode(V₁, V₂)—contact the soles of the feet of the patient 250, and thecurrent-injecting electrodes I₁ and I₂ inject high-frequency (e.g. 70kHz), low-amperage (e.g. 4 mA) current into the patient's feet. Thecurrent injected by each electrode is suitably out of phase by 180° withrespect to the current injected by the other electrode. Electrode V₁measures the resistance (or impedance) encountered by the propagatingcurrent injected by electrode I₂ (as a voltage, per Ohm's Law), andelectrode V2₂ measures the resistance (or impedance) encountered by thepropagating current injected by electrode I₁.

As current propagates through the patient's body, it scatters off ofbone, skin, organs, etc., as indicated by the meandering line 258 shownin the figure. Typically, such tissue has static electrical impedanceproperties, i.e., properties that are relatively constant in time. Thus,they contribute to a “background” or DC signal component in the BImeasurement.

On the other hand, in contrast, tissue in a region 256 near the chestcontains physiological components that vary with time and thuscontribute to a variant or AC signal component in the BI measurement.For example, blood, which is a relatively good electrical conductor,flows from the left ventricle into the aorta with each heartbeat, andits contribution to the BI signal is a heartbeat-induced pulsatilesignal, called an impedance plethysmogram, such as that shown in FIG.7C. Blood flowing in other vessels will also contribute to the amplitudeof pulses in the plethysmogram, but the contribution from the aorta ispredominant, as noted above. Furthermore, fluid such as lung fluid inthe region 256 also conducts electricity, and thus contributes to the BIsignal. However, such fluid levels vary relatively slowly (i.e., muchslower that pulsatile blood flow), and thus changes in this signalcomponent occur on a much slower time scale.

With a floormat configuration like that described above, where all fourelectrodes are located on the upper surface of the floormat, current(indicated by the line 258) propagates from one foot to the otherthrough a somewhat circuitous path and may have limited presence in theregion 256 responsible for AC components of the BI signal due, forexample, to time-dependent physiological events such asheartbeat-induced blood flow and fluid change.

However, as illustrated in FIG. 11B, if one of the pairs 254 ofelectrodes (e.g., I₂ and V₁) are placed near the hand, the region 256responsible for AC contributions to the BI signal is exposed to arelatively large amount of injected current and thus may yield astronger signal BI, especially as it relates to blood and fluid flow.Thus, a floormat embodiment that includes electrodes that contact thepatient's feet and a hand, as described in more detail, may be preferredin some circumstances.

8. Mechanical Form Factors for the Floormat

FIGS. 12-14 show different embodiments of a floormat according to theinvention that include electrodes which contact both the hands and feet.As shown in FIGS. 12A and 12B, in some embodiments, the floormat 300features a base portion 319 and a hand-held portion 318. The baseportion 319 includes a pair of electrodes 312, 314 that serve,respectively, as single current-injecting (i.e., I_(x)) andvoltage-measuring (i.e., V_(x)) electrodes, as described above. The sameelectrodes are used to measure ECG waveforms and bioreactance signals,which, as described above are used to estimate percent body fat andmuscle mass. Typically, the electrodes are located on the floormat's topsurface 317, usually made from a silicone rubber, and are disposed wherethe patient's right foot would rest during a measurement.

The top surface 317 also supports an air-filled bladder 316 and anelectronics module 310. The air-filled bladder 316 receives thepatient's left foot 320 during a measurement, and it is similar to thatshown in FIG. 4A-C. During a measurement, a pressure-delivery system,similar to that described above, inflates and then deflates theair-filled bladder 316 as part of a blood pressure measurement.

Within the air-filled bladder 316 is an optical system featuring a lightsource and a photodiode that, collectively, measure PPG waveforms usingLEDs that emit in both the red and infrared spectral regions, asdescribed above. The PPG waveform is processed as described above tomeasure both blood pressure and SpO2. The electronics module 310includes analog electronics to determine the BI, ECG, PPG, and pressurewaveforms, along with digital electronics such as an analog-to-digitalconverter, microprocessor, and Bluetooth® system for processing thesewaveforms to determine physiological parameters and then transmittingthe physiological parameters and waveforms to a mobile device 307, e.g.,a smartphone or tablet computer.

The hand-held portion 318 connects through and is supported by a hollowpole 301 extending from the base portion 319. The hand-held portion 318includes complementary current-injecting electrodes 303, 305 andvoltage-measuring electrodes 302, 304 that work in concert with thoseelectrodes 312, 314 in the base portion 319. The hand-held portion 318also includes a mounting platform 307 to support the patient's mobilephone 306 during a measurement. Because they make a differentialmeasurement, the current-injecting electrodes 303, 305 are wiredtogether, as are the voltage-measuring electrodes 302, 304. In this way,each wired pair functions essentially as a single electrode.

During a measurement, the patient holds on to the hand-held portion 318so that the current-injecting electrode 303 and the voltage-measuringelectrode 302 are contacted by the patient's left hand, and thecomplementary current-injecting electrode 305 and voltage-measuringelectrode 304 are contacted by the patient's right hand. The mountingplatform 307 supports the patient's mobile phone 306 so that it is neareye level and easy to see. A standard, flexible cable (not shown in thefigure) connects to the electrodes 302, 303, 304, 305 and passes throughthe hollow pole 301, where it connects to a corresponding circuit in theelectronics module 310, along with a similar cable extending from theelectrodes 312, 314 in the base portion 319.

A GUI operating on the mobile device 307 guides the patient through ameasurement and, in turn, displays waveforms and physiologicalparameters as described above. Once the measurement is complete, themobile device 307 transmits any numerical values and/or waveformsthrough a second wireless interface, e.g. WiFi® or cellular system, to acloud-based system, as illustrated schematically in FIG. 1.

Suitably, the hollow pole 301 shown in the figure is somewhat rigid andthus, for example, helps stabilize the patient and potentially keepsthem from falling over during a measurement.

For an alternate embodiment of the floormat 350, as shown in FIGS. 13A,13B, the hollow pole of FIG. 12A, 12B can be replaced by a flexiblecable 351. The flexible cable 351 is essentially the same as theflexible cable referenced with respect to FIG. 12A, 12B. Unlike thehollow pole 301, however, the flexible cable 351 provides essentially nomechanical support to the patient. However, its flexible nature means itcan be moved around easily during a measurement, and it is ideallysuited to be held by patients of a variety of heights.

In still another embodiment of the invention, as shown in FIG. 14A, 14B,the floormat 450 features a flexible cable 451 that connects to ahand-held portion 418 designed for just a single hand. The hand-heldportion 418 includes a grip 453 featuring a single current-injectingelectrode 454 and a single voltage-measuring electrode 452. Theelectrodes 452, 454 connect to the electronics module 310 in the baseportion 319 through a flexible cable 451 similar to that describedabove, but only containing wires for just the single electrodes 452,454. In this case, the hand-held portion 418 lacks any type of mount forthe mobile device.

In general, the overarching purpose of a floormat according to theinvention, as described above, is to make daily measurements of a widerange of physiological parameters that, in turn, can be analyzed todiagnose specific disease states. It is often the time-dependent trendsin the physiological parameters that provide the best indication of suchdisease states. At a simple level, for example, a patient's weight valueof 200 pounds his limited clinical value by itself. However, a weightvalue that rapidly increases from 200 to 210 pounds over a period of afew days may indicate the onset of a disease, such as CHF. In general,it is a collection of trends in multiple physiological parameters thatoften serve as the best marker for the onset of disease states. In thisregard, FIG. 15 shows, for example, a table 500 indicating how trends indifferent physiological parameters can be used to diagnose diseasestates such as hypertension, cardiac disease, heart failure, renalfailure, chronic obstructive pulmonary disease (COPD), diabetes, andobesity. In addition, the table 500 indicates how such trends may showbeneficial progress to a population actively involved in exercise.

Embodiments other than those described above are within the scope of theinvention. For example, the mechanical configuration of the floormat cantake many shapes. In one embodiment, the floormat has a mechanicalconfiguration similar to that of a conventional weight scale. Here, itmay feature a rigid base, four distinct feet, and a cross-sectionalshape that is relatively square. In an alternative embodiment, thefloormat may feature the mechanical configuration of a conventional yogamat and would be made with a flexible material (e.g. foam or siliconerubber) that can be easily rolled. In that case, electronic componentsrequired to measure all of the above-mentioned parameters would beembedded in the flexible material and may connect through flexibleelectronics, e.g. a flex circuit made from a polymeric material such asKapton. Or the floormat may feature a rigid base and a surroundingflexible portion that can be removed, washed, and customized for thepatient. Other mechanical configurations are also possible, such as onethat includes foot-worn enclosures, e.g. something resembling a slipper,sandal, or shoe. In that case, electronics would be embedded in thesoles of the foot-worn enclosures, which would typically connect to eachother with a wire or flexible circuit.

In a preferred embodiment such as the one described above, the floormatdoes not feature a display. Omission of a display reduces costs andcomplexity associated with manufacturing and simplifies the floormat'sdesign. Additionally, most patients using the floormat will have aconventional mobile device, such as a smartphone or tablet, and suchdevices typically have high-resolution displays (e.g., those featuringorganic LED or liquid crystals) that are driven by sophisticatedoperating systems, and such systems can easily display all the numericaland waveform information generated by the floormat.

Alternatively, the floormat may include a simple display, e.g., one thatdisplays basic waveform information. In most cases, the floormat willinclude one or more colored LEDs that indicate its overall status, e.g.,its battery power; whether or not a measurement is ready to start or iscomplete; and if an error was present during the measurement.

Sensors and electronics other than those described above can be used forthe floormat. For example, while a Wheatstone Bridge is a conventionalcircuit for measuring weight, this sensor can be replaced by somethingmore suitable to the floormat's form factor, e.g., a thin,pressure-sensitive resistor such as that manufactured by Tekscan(www.tekscan.com). Likewise, the circuitry described above for measuringBI, ECG, and PPG waveforms can be replaced by an alternative circuitthat performs a similar function. Furthermore, wireless transmitters,e.g. the Bluetooth®, WiFi®, and cellular transmitters described above,can be replaced by other short- or long-range radios that performessentially the same function.

Other sensors not described in detail above may be incorporated into thefloormat. For example, the hand-held component shown in FIGS. 12-14 mayinclude other sensing components. In various embodiments, the hand-heldcomponent may include an optical system similar to that described above.This may be used, for example, to measure SpO2 values and PPG waveformsfrom the hands or fingers. The PPG waveforms may then be used tocalculate PAT and VTT and then used to measure blood pressure, asdescribed above. In still other embodiments, the hand-held component mayinclude a spirometer or end-tidal CO2 sensor to measure respirationrate, expelled gasses, and respiratory effort. The hand-held componentmay also include a glucometer for measuring glucose levels in thepatient's blood or an ultrasound sensor for taking simple, Doppler-typeimages from the patient. In other embodiments, the hand-held componentmay include a camera for taking a picture of the patient or a portion ofthe patient, e.g., a lesion or a growth. In other embodiments, thefloormat may link to other conventional wearable devices, such asdevices that track a patient's activity and/or HR during exercise ordevices such as ambulatory blood pressure monitors.

The GUI operating on the mobile device may serve many differentfunctions. As described above, its primary function is to displaynumerical and waveform information from the patient. Additionally, itmay: i) display trends in these values; ii) indicate a particulardisease state (such as those listed in the table shown in FIG. 15); iii)prompt the patient to step on the floormat; iv) link the floormat to awebsite involving social media or to a website viewable by family,friends, or a pre-approved clinician; v) provide guidance to the patienton managing their condition; vi) be used to enter biometric informationthat is not measurable by the floormat, such as the patient's age,height, race, or gender; vii) estimate and render the patient's physicalage (based on parameters such as body-mass index and HR); viii) trackthe patient's performance vs. goals; ix) compare data measured from thepatient to other data (e.g. in their age group) to promote competition;and x) show advertisements from relevant vendors. Other software-basedapplications are, of course, possible with the mobile device and itsassociated GUI.

In other embodiments, the floormat described above can integrate with a‘patch’ that directly adheres to a portion of a patient's body, or a‘necklace’ that drapes around the patient's neck. The patch would besimilar in form to the necklace's base, although it may take on othershapes and form factors. It would include most or all of the samesensors (e.g. sensors for measuring ECG, TBI, and PPG waveforms) andcomputing systems (e.g. microprocessors operating algorithms forprocessing these waveforms to determine parameters such as HR, HRV, RR,BP, SpO2, TEMP, CO, SV, fluids) as the base of the necklace. Howeverunlike the system described above, the battery to power the patch wouldbe located in or proximal to the base, as opposed to the strands in thecase of the necklace. Also, in embodiments, the patch would include amechanism such as a button or tab functioning as an on/off switch.Alternatively, the patch would power on when sensors therein (e.g. ECGor temperature sensors) detect that it is attached to a patient.

In typical embodiments, the patch includes a reusable electronics module(shaped, e.g., like the base of the necklace) that snaps into adisposable component that includes electrodes similar to those describedabove. The patch may also include openings for optical and temperaturesensors as described above. In embodiments, for example, the disposablecomponent can be a single disposable component that receives thereusable electronics module. In other embodiments, the reusableelectronics module can include a reusable electrode (made, e.g., from aconductive fabric or elastomer), and the disposable component can be asimple adhesive component that adheres the reusable electrode to thepatient.

In preferred embodiments the patch is worn on the chest, and thusincludes both rigid and flexible circuitry, as described above. In otherembodiments, the patch only includes rigid circuitry and is designed tofit on other portions of the patient's body that is more flat (e.g. theshoulder).

In embodiments, for example, the system described above can calibratethe patch or necklace for future use. For example, the floormat candetermine a patient-specific relationship between transit time and bloodpressure, along with initial values of SYS, DIA, and MAP. Collectivelythese parameters represent a cuff-based calibration for blood pressure,which can be used by the patch or necklace for cuffless measurements ofblood pressure. In other embodiments, the floormat can measure afull-body impedance measurement and weight. These parameters can bewirelessly transmitted to the necklace or patch, where they are usedwith their impedance measurement to estimate full-body impedance (e.g.during a dialysis session). Additionally, during the dialysis session,the necklace or patch can use the values of full-body impedance andweight to estimate a progression towards the patient's dry weight.

These and other embodiments of the invention are deemed to be within thescope of the following claims.

What is claimed is:
 1. A system for measuring a stroke volume value froma patient, comprising: a base comprising a bottom surface configured torest on or near a substantially horizontal surface, and a top surfaceconfigured to receive at least one of the patient's feet; an electricalimpedance system connected to the top surface, the electrical impedancesystem comprising at least four electrodes, at least one of which isconfigured to inject an electrical current into the patient's feet, andat least one of which is configured to measure a signal induced by theelectrical current and representative of an impedance plethysmogram; anda processing system in electrical contact with the electrical impedancesystem, and configured to receive signals from the electrical impedancesystem and convert them into a set of impedance values, the processingsystem further configured to analyze the set of impedance values todetermine the stroke volume value.
 2. The system of claim 1, wherein theelectrical impedance system comprises an electrical system that injectsa current modulated at a frequency between 25-125 kHz.
 3. The system ofclaim 1, wherein the electrical impedance system comprises an electricalsystem that comprises two electrodes that inject the electrical current,wherein both electrodes are disposed on the top surface, and oneelectrode is located substantially on the left-hand side of the topsurface and configured to inject electrical current into the patient'sleft foot, and one electrode is located substantially on the right-handside of the top surface and configured to inject electrical current intothe patient's right foot.
 4. The system of claim 3, wherein theelectrical impedance system comprises an electrical system thatcomprises two electrodes, each configured to measure a signal induced bythe electrical current, wherein both electrodes are connected to the topsurface, and one electrode is located substantially on the left-handside of the top surface and configured to measure a signal from thepatient's left foot, and one electrode is located substantially on theright-hand side of the top surface and configured to measure a signalfrom the patient's right foot.
 5. The system of claim 1, furthercomprising a hand-held component that comprises at least two electrodes.6. The system of claim 5, wherein the electrical impedance systemcomprises an electrical system that comprises two electrodes that injectthe electrical current, wherein one electrode is disposed on the topsurface, and one electrode is comprised by the hand-held component. 7.The system of claim 5, wherein the electrical impedance system comprisesan electrical system that comprises two electrodes that measure a signalinduced by the electrical current, wherein one electrode is disposed onthe top surface, and one electrode is comprised by the hand-heldcomponent.
 8. The system of claim 1, wherein the processing systemcomprises computer code configured to analyze the set of impedancevalues to determine the stroke volume value.
 9. The system of claim 1,wherein the computer code is configured to calculate a derivative of theset of impedance values to determine a dΔZ(t)/dt waveform.
 10. Thesystem of claim 9, wherein the computer code is configured to determinea maximum value of the dΔZ(t)/dt waveform.
 11. The system of claim 10,wherein the computer code is configured to determine an area of a pulsein the dΔZ(t)/dt waveform.
 12. The system of claim 10, wherein thecomputer code is configured to estimate an ejection time from thedΔZ(t)/dt waveform.
 13. The system of claim 9, wherein the computer codeis configured to estimate a baseline impedance (Z₀) from the set ofimpedance values.
 14. The system of claim 13, wherein the computer codeis configured to determine: i) a maximum value of the dΔZ(t)/dt waveform((dΔZ(t)/dt)_(max)); and ii) a left ventricular ejection time (LVET)from the dΔZ(t)/dt waveform.
 15. The system of claim 14, wherein thecomputer code is configured to determine stroke volume (SV) from theequation:$S\; V\text{∼}\frac{( {d\; \Delta \; {{Z(t)}/{dt}}} )_{\max}}{Z_{o}} \times L\; V\; E\; T$16. The system of claim 14, wherein the computer code is configured todetermine stroke volume (SV) from the equation:$S\; V\text{∼}\sqrt{\frac{( {d\; \Delta \; {{Z(t)}/{dt}}} )_{\max}}{Z_{o}}} \times L\; V\; E\; T$17. The system of claim 1, further comprising a weight-measuring systemconnected to the top surface, the weight-measuring system comprising anelectrical system that measures a set of voltages that correlates with aforce applied to the top surface.
 18. The system of claim 17, whereinthe processing system is further configured to receive the set ofvoltages, and analyze them to determine a value of weight placed on thetop surface.
 19. The system of claim 18, wherein the computer code isconfigured to determine stroke volume (SV) from the equation:${S\; V} = {V_{c} \times \frac{( {d\; \Delta \; {{Z(t)}/{dt}}} )_{\max}}{Z_{o}} \times L\; V\; E\; T}$where V_(c) is a volume conductor calculated from the value of weight.20. The system of claim 18, wherein the computer code is configured todetermine stroke volume (SV) from the equation:${S\; V} = {V_{c} \times \sqrt{\frac{( {d\; \Delta \; {{Z(t)}/{dt}}} )_{\max}}{Z_{o}}} \times L\; V\; E\; T}$where V_(c) is a volume conductor calculated from the value of weight.21. A system for measuring a stroke volume value from a patient,comprising: a base comprising a bottom surface configured to rest on ornear a substantially horizontal surface, and a top surface configured toreceive at least one of the patient's feet; an electrical impedancesystem connected to the top surface, the electrical impedance systemcomprising at least four electrodes, at least one of which is configuredto inject an electrical current into the patient's feet, and at leastone of which is configured to measure a signal induced by the electricalcurrent and representative of an impedance plethysmogram; aweight-measuring system connected to the top surface, theweight-measuring system comprising an electrical system that measures aset of voltages that correlates with a force applied to the top surface;and a processing system in electrical contact with the electricalimpedance system, and configured to receive signals from the electricalimpedance system and convert them into a set of impedance values, theprocessing system further configured to analyze the set of impedancevalues to determine the stroke volume value.
 22. The system of claim 21,wherein the electrical system comprises a Wheatstone Bridge.
 23. Thesystem of claim 22, wherein the Wheatstone Bridge connects electricallywith an amplifier system.
 24. The system of claim 23, wherein theprocessing system is further configured to receive the set of voltages,and analyze them to determine a value of weight corresponding to theforce applied on the top surface.
 25. The system of claim 21, whereinthe electrical impedance system comprises an electrical system thatinjects a current modulated at a frequency between 25-125 kHz.
 26. Thesystem of claim 21, wherein the electrical impedance system comprises anelectrical system that comprises two electrodes that inject theelectrical current, wherein both electrodes are disposed on the topsurface, and one electrode is located substantially on the left-handside of the top surface and configured to inject electrical current intothe patient's left foot, and one electrode is located substantially onthe right-hand side of the top surface and configured to injectelectrical current into the patient's right foot.
 27. The system ofclaim 26, wherein the electrical impedance system comprises anelectrical system that comprises two electrodes, each configured tomeasure a signal induced by the electrical current, wherein bothelectrodes are connected to the top surface, and one electrode islocated substantially on the left-hand side of the top surface andconfigured to measure a signal from the patient's left foot, and oneelectrode is located substantially on the right-hand side of the topsurface and configured to measure a signal from the patient's rightfoot.
 28. The system of claim 21, further comprising a hand-heldcomponent that comprises at least two electrodes.
 29. The system ofclaim 28, wherein the electrical impedance system comprises anelectrical system that comprises two electrodes that inject theelectrical current, wherein one electrode is disposed on the topsurface, and one electrode is comprised by the hand-held component. 30.The system of claim 28, wherein the electrical impedance systemcomprises an electrical system that comprises two electrodes thatmeasure a signal induced by the electrical current, wherein oneelectrode is disposed on the top surface, and one electrode is comprisedby the hand-held component.
 31. The system of claim 21, wherein theprocessing system comprises computer code configured to analyze the setof impedance values to determine the stroke volume value.
 32. The systemof claim 21, wherein the computer code is configured to calculate aderivative of the set of impedance values to determine a dΔZ(t)/dtwaveform.
 33. The system of claim 32, wherein the computer code isconfigured to determine a maximum value of the dΔZ(t)/dt waveform. 34.The system of claim 33, wherein the computer code is configured todetermine an area of a pulse in the dΔZ(t)/dt waveform.
 35. The systemof claim 33, wherein the computer code is configured to estimate anejection time from the dΔZ(t)/dt waveform.
 36. The system of claim 32,wherein the computer code is configured to estimate a baseline impedance(Z₀) from the set of impedance values.
 37. The system of claim 36,wherein the computer code is configured to determine: i) a maximum valueof the dΔZ(t)/dt waveform ((dΔZ(t)/dt)_(max)); and ii) a leftventricular ejection time (LVET) from the dΔZ(t)/dt waveform.
 38. Thesystem of claim 37, wherein the computer code is configured to determinestroke volume (SV) from the equation:$S\; V\text{∼}\frac{( {d\; \Delta \; {{Z(t)}/{dt}}} )_{\max}}{Z_{o}} \times L\; V\; E\; T$39. The system of claim 37, wherein the computer code is configured todetermine stroke volume (SV) from the equation:$S\; V\text{∼}\sqrt{\frac{( {d\; \Delta \; {{Z(t)}/{dt}}} )_{\max}}{Z_{o}}} \times L\; V\; E\; T$40. The system of claim 21, wherein the processing system is furtherconfigured to process the set of voltages that correlates with the forceapplied to the top surface to determine a weight value corresponding tothe weight placed on the top surface.
 41. The system of claim 40,wherein the computer code is configured to determine stroke volume (SV)from the equation:${S\; V} = {V_{c} \times \frac{( {d\; \Delta \; {{Z(t)}/{dt}}} )_{\max}}{Z_{o}} \times L\; V\; E\; T}$where V_(c) is a volume conductor calculated from the weight value. 42.The system of claim 40, wherein the computer code is configured todetermine stroke volume (SV) from the equation:${S\; V} = {V_{c} \times \sqrt{\frac{( {d\; \Delta \; {{Z(t)}/{dt}}} )_{\max}}{Z_{o}}} \times L\; V\; E\; T}$where V_(c) is a volume conductor calculated from the weight value.